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RC261  .H33  Skin  cancer,  by  Henr 


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SKIN  CANCER 


Prickle-cellefl    rancer   originating   in   an    old    lupus   vulgaris    lesion. 
(Collection  of  Dr.   M.   L.    Heiding.sfeld.) 


SKIN    CANCER 


BY 


HENKY  H.  HAZEN,  A.B.,  M.D. 

PROFESSOR    OF    DERMATOLOGY    IN    THE    MEDICAL    DEPARTMENT    OF    GEORGETOWN    tTNI- 

VERSITY;    PROFESSOR    OF    DERMATOLOGY    IN    THE    MEDICAL    DEPARTMENT    OF 

HOWARD  UNIVERSITY;    SOMETIME  ASSISTANT   IN   DERMATOLOGY   IN 

THE    JOHNS    HOPKINS    UNIVERSITY;    MEMBER    OF    THE 

AMERICAN    DERMATOLOGICAL    ASSOCIATION. 


WITH  NINETY-SEVEN   TEXT  ILLUSTRATIONS,  AND    ONE 
COLORED  FRONTISPIECE 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1916 


h 


-iq^ 


Copyright,  1016,  by  C.  V.  Mosby  Company 


Press  of 

C.  V.  Mosby  Company 

St.  Louis 


TO 
WILLIAM  STEWART  HALSTED 

A  True  Student  of  Cancer. 


PREFACE 

When  one  considers  that  epithelial  growths  of  the  skin,  both  be- 
nign and  malignant,  are  so  common,  that  they  are  usually  so  easily 
diagnosed,  that  the  tissue  from  them  is  readily  obtainable  for  histo- 
logical study,  and  that  most  of  them  are  so  amenable  to  proper  treat- 
ment, it  is  surprising  how  much  ignorance  prevails  concerning  them, 
even  among  surgeons  and  dermatologists.  In  this  country  BUkxI- 
good  has  done  much  to  correlate  the  clinical  and  pathological  find- 
ings, and  to  point  out  how  these  different  findings  influence  treat- 
ment, for  the  treatment  of  tumors  of  the  skin  must  be  conducted  by 
different  procedures  according  to  their  malignancy. 

In  this  book  an  effort  has  been  made  to  gather  under  one  cover  the 
latest  views  on  malignant  tumors  of  the  skin,  and  to  give  the  per- 
sonal experience  of  the  author,  an  experience  gained  in  Dr.  Blood- 
good's  surgical  pathological  department  of  the  Johns  Hopkins  Hos- 
pital, in  Dr.  Gilchrist's  dermatological  clinic  at  the  same  institu- 
tion, and  in  the  surgical,  pathological,  and  dermatological  depart- 
ments of  the  Freedmen's  and  Georgetow^n  University  hospitals. 

The  aim  of  the  book  is  to  be  both  scientific  and  practical — to  give 
the  correct  pathology  of  the  cutaneous  neoplasms,  and  to  point  out 
hoAV  this  guides  treatment. 

It  is  a  pleasure  to  thank  my  friends  for  the  help  that  they  have 
given  me,  in  the  referring  of  cases  for  study,  in  the  preparation 
of  pathological  material,  and  in  furnishing  me  photographs.  I\Iy 
thanks  are  due  to  Dr.  Richard  L.  Sutton,  of  Kansas  City ;  Dr.  31.  L. 
Heidingsfeld,  of  Cincinnati;  Dr.  C.  J.  White,  of  Boston;  Dr.  George 
M.  MacKee,  of  New  York;  Dr.  Perkins,  of  Kansas  City;  and  Dr. 
Gilchrist  for  illustrations.  Both  Dr.  Gilchrist  and  Dr.  E.  A.  Bal- 
loch,  of  Washington,  have  allowed  me  to  make  free  use  of  their  ma- 
terial. Dr.  Wm.  B.  Sowers,  of  Washington,  for  several  years  resi- 
dent surgeon  at  the  Johns  Hopkins  Hospital,  has  written  the  en- 
tire subject  of  carcinoma  of  the  lip,  and  Dr.  H.  A.  Fowler,  of  Wash- 
ington, has  helped  me  with  the  subject  of  cancer  of  the  penis.  Dr. 
Van  Sweringen,  pathologist  to  Freedmen's  Hospital,  has  prepared 
many  sections  for  me. 

H.  H.  Hazex. 
Washington,  D.  C. 


CONTENTS 


CHAPTF^R  I.  f'AOK 

General  Coxsideuations 17 

Definition  and  Concei^tion — Classification — Structure — Growtli  of  Tumors 
— Toxins — Tiiimiiiiity — J']tioIo;;y — Inciilontal  Fact07'3. 

CHAPTER  II. 

PUECANCEllOUS     DERMATOSES  35 

Pigmented  Moles — Seborrheic  Warts — Simple  Keratosis — Arsenical  Ker- 
atoses— Keratosis  Follicularis — Cutaneous  Horn — Cancer  of  Paraffin 
Workers — Xeroderma  Pigmentosum — Sailor 's  Skin — Farmer 's  Cancer — 
X-Ray  Dermatitis — Paget 's  Disease — Marjolin's  Ulcer — Lupus  Vulgaris 
— Leg  Ulcers — Lupus  Erythematosus — Blastomycosis — Syphilis — Inflam- 
matory Dermatoses — Sinuses — Wens — jSTevi — Papillomas — Conclusions. 

CHAPTER  IIL 

Epithelial  Warts 52 

Benign  Warts — Malignant  Cutaneous  Warts 

CHAPTER  IV. 
Basal-Celled   Carcinomata       59 

Classification  of  Basal-Celled  Careinomata— Flat  Rodent  Ulcers — Xodular 
Cancers — Rolled-Edge  Rodent  Ulcers — Depressed  Scar-Like  Cancer — Mor- 
phea-Like  Cancer — Fungating  Tumors — Deep  Ulcers — Diagnosis — Treat- 
ment. 

CHAPTER  V. 
Cubo-Celled  Caecinomata 81 

CHAPTER  A'l. 
Spino-Celled  Carcinomata 84 

CHAPTER  VII. 

Benign  and  Malignant  Tumors  of  the  Cutaneous  Appendages     ....    92 
Tumors  of  the  Hair  Follicles — Tumors  of  the  Sebaceous  Glands — Tumors 
of  the  Sweat  Glands — Tumors  of  the  Sweat  Ducts. 

CHAPTER  VIII. 
Multiple  Benign   Tumors 102 

Multiple  Benign  Cystic  Epithelioma — Syringocystadenoma — Adenoma 
Sebaceum. 

CHAPTER  IX. 

NEVOCAKCINOilATA    AND    MALIGNANT    MeLANOMATA Ill 

11 


12  CONTEXTS. 

CHAPTER  X.  PAGE 

Cakcinoma   ek   Cuikasse — Cakcinoma   by   Extension — Metastatic   Cauci- 

NOMA — Facet's   Disease 119 

CHAPTER  XI. 
Exdotheliomata 127 

Xevo-xantho-ciulothcliomata 

CHAPTER  XII. 

Benign  Connective  Tissue  Tumors 132 

Cicatrix — Keloid — Fibroma — Fibroma  Molluscum — Neuroma — Myoma — 
Lipoma — Osteoma — Hemangioma — Lymphangioma — Lymphangioma  Cir- 
cumscriptum. 

CHAPTER  XIIL 

Sarcomata  and   Sarcoids 137 

Sarcomata — Solitary  Lesions — Multiple  Lesions — Transitional  Lesions — 
Sarcoids. 

CHAPTER  XIV. 
Lympiiomata 14S 

CHAPTER  XV. 
Differential  Diagnosis 15-t 

CHAPTER  XVI. 
Prognosis 169 

CHAPTER  X\T[I. 
Prophylaxis 173 

CHAPTER  XVIII. 

Treatment 1"8 

Surgical — Electrical — Actinic — Caustics — Congelation — Medication — 
Treatment    of    Complications — Treatment    of    Inoperable   Cases — Repair 
of  Deformities. 

CHAPTER  XIX. 
Tumors  According  to  Location 207 


ILLUSTIiMIONS 


Priokle-cellkd  Cancer Frontispiece 

FIG.  PAOE 

1.  Photomicrogruph   of   uu   oidiuaiy   pigmented   mole 36 

2.  Common  mole  of  the  neck 3G 

3.  Fungous  cancer 38 

4.  Horny   growth    upon    the    liaiid 40 

5.  Cutaneous  horn 41 

6.  Xeroderma  pigmentosum 43 

7.  Xeroderma  pigmentosum 44 

8.  Lupus   vulgaris 48 

9.  Photomicrograph   of   lesions   of   molluscum   contagiosum 54 

10.  Diagram  of  sites  of  origin  of  220  cases  of  basal-celled  cancer     .     .     .     .  o'J 

11.  Photomicrograph  showing  basal-celled  carcinomata 60 

12.  Photomicrogra])h  showing  downgrowth  of  the  epithelium 61 

13.  Photomicrograph  showing  a  clubbing  of  the  downgrowth 62 

14.  Downgrowth  contracts,  so  that  solid  mass  of  basal  cells  is  formed     ...  62 

15.  Photomicrograph  showing  ulceration  of  epithelium 63 

16.  Photomicrograph  showing  section  from  a  typical  rolled-edge  rodent  ulcer 

of     the     shoulders 64 

17.  Photomicrograph  demonstrating  the  manner  in  which  a  basal-celled  cancer 

may  be  covered  by  normal  epithelium 65 

18.  Photomicrograph  of  a  basal-celled  carcinoma 65 

19.  Basal-celled  cancer  of  the  chin 66 

20.  Multiple  basal-celled  cancers 67 

21.  Flat  basal-celled  carcinoma  of  the  nose 68 

22.  Basal-celled  cancer  of  many  years'   duration 69 

23.  Basal-celled  cancer  spontaneously  healed  in  center 70 

24.  Early  basal-celled   carcinoma  of   the  hand 71 

25.  Nodular  basal-celled  carcinoma  of  the  cheek 72 

26.  Basal-celled  cancer  of  the  hand 73 

27.  Basal-celled   cancer   of   the   forehead 74 

28.  Eolled-edge  rodent  ulcer  of  the  neck 75 

29.  Morphea-like    epithelioma 76 

30.  Cuboidal-celled    cancer 82 

31.  Deep  prickle-celled  cancer  of  cheek  in  a  young  man 85 

32.  Eapid  growing  cancer  developing  from  within  the  ear 86 

S3.  Prickle-celled  cancer  originating  in  the  mastoid  following  mastoid  opera- 
tion        87 

34.  Photomicrograph    of    prickle-celled    cancer 88 

35.  Epithelial  pearls  in  a  squamous-celled  cancer 89 

36.  Carcinoma  originating   in  hair   follicles 94 

37.  Carcinoma  of  the  buttock 97 

38.  Photomicrograph  of  adenoma  of  the  sweat  ducts 99 

13 


14  ILLUSTRATIONS. 

no.  PAGE 

39.  PliotoiHifiugia|ih  of  ailommia  of  the  sweat  ducts 100 

■iO.  Multiple  lu'iiij,'!!  cystic  epithelioiua 103 

41.   riiotomicro^iaiili   nf   imiitipio   benign   cystic   epitlielioma 10-1 

4'2.  SyringocystaileHoina 105 

43.  Photoniicrogiaph  of  syiingocystadenonia 10(5 

44.  Pliotoniicrogiapli  of  syringocystaileiionia 107 

43.  Adenoma  sel>aceuni 108 

ir..   Mdlluseum  contagiosuin 109 

47.  Xevucaicinonui 11- 

48.  Malignant   pignientetl   nmle ll-'« 

49.  Photomicrograph  of  a  malignant  pigmented  mole    (nevocaicinoma)      .     .lit! 

50.  Photomiciogiaph   of   malignant   mole 117 

51.  Caicinoma    en    cuiiasse 120 

52.  Extension  of  carcinoma  of  the  breast 121 

53.  Histology  of  Paget 's  disease 124 

54.  Histology  of   lymphangioendothelioma 130 

55.  Photomicrograph  of  small  round-celled  sarcoma  of  skin 139 

50.  Multiple     sarcomata 142 

57.  Multiple    hemorrhagic    sarcoma 145 

58.  Mycosis  fungoides 151 

59.  Hypertrophy    of    the    epidermis 157 

60.  Chancre  of  the  chin 158 

(jl.  Chancre  of  the  lip 159 

62.  Gumma  of  the  nose 160 

03.  Gummatous  lesion  of  the  lip IGl 

64.  Lupus  vulgaris,  showing  spontaneous  healing  in  center 162 

65.  Tuberculous    ulceration 16.". 

{j(].  Diffuse    papillomatosis    of    skin 164 

67.  Tuberculosis   verrucosa    cutis 165 

68.  Blastomycosis 166 

69.  Basal-celled  epithelioma 190 

70.  Basal-celled  epithelioma,  after  treatment 191 

71.  Endothelioma  capitis 208 

72.  Ba.sal-celled   carcinoma   of   the    fureliead 209 

73.  Basal-celled  cancer  of  eyelid 210 

74.  Basal-celled  cancer  of  the  nose 211 

75.  Seborrheic   keratosis   of  the  lip 214 

76.  Seborrheic  keratosis  of  the  lower  lip 215 

77.  Ulcerated  prickle-celled  carcinoma  of  the  lower  lip 216 

78.  Prickle-celled  carcinoma  of  the  lower  lip 217 

79.  Fungating  carcinoma  of  the  lower  \\[> 218 

80.  FuJigating  cancer  of  the  lower  lip 219 

51.  Prickle-celled  cancer  of  the  lower  lii> 220 

82.  Prickle-celled  cancer  of  the  lower  lip 221 

83.  Prickle-cellcd   cancer   of   the    upper    lip 222 

84.  Relationship  of  the  deep  lymphatics  to  otiier  structures  of  the  neck     .     .  224 

85.  Method  of  repairing  a  defect  caused  by  the  excision  of  a  V-shaped  piece 

of  the  lip 225 


ILLUSTRATIONS.  15 

FIG.  PAGE 

8G.  Same   as   Fig.    85 226 

87.  Mayo's  method   for   rciiioving   liiinor 227 

88.  Same   as   Fig.   87 22S 

89.  Plastic  operation  for  repairing  defects  after  removal  of  cancer  of  the  lip  220 
00.  Same   as    Fig.   8!) 2.';0 

91.  Same   as   Fig.   SO 2:jl 

92.  Crile's  incision  for  removal  of  cancer  of  tiic  lip ...  2'j2 

93.  Same  as  Fig.  92 2.33 

94.  Same  as  Fig.  92 234 

95.  Same  as  Fig.  92 2.35 

9G.  Same  as  Fig.  92 236 

97.  Cancer  of  the  tongue 238 


81vL\     CyVN(  i:iJ 

CHAPTER  I. 
GENERAL  CONSIDERATI OXS. 

DEFINITION  AND  CONCEPTION. 

Ill  1863  Virchow^  stated  that  it  was  practically  impossible  to  give 
a  satisfactory  definition  of  a  tumor,  and  many  -writers  since  that 
time  have  unwittingly  proven  the  truth  of  that  statement.  In  deal- 
ing with  epithelial  neoplasms  we  may,  however,  say  that  any  auton- 
omous growth  of  epithelial  cells,  or  of  cells  derived  from  the  epi- 
thelium, constitute  a  neoplasm.  We  are  not  dealing  with  inflam- 
matory masses  or  with  cysts,  although  either  of  these  conditions  can, 
and  do,  give  rise  to  tumors,  sometimes  clinically  indistinguishable 
from  true  neoplasms. 

CLASSIFICATION. 

A  thoroughly  satisfactory  classification  of  epithelial  tumors  has 
not  yet  been  made.  For  this  there  are  many  reasons ;  first  and  fore- 
most, because  until  a  few  years  ago  the  pathology  was  not  thorough- 
ly studied,  and  no  one  recognized  that  a  tumor  showing  one  type  of 
structure  might,  in  the  natural  course  of  events,  come  to  present  a 
totally  different  histological  picture,  although  the  same  cell  type  was 
always  preserved.  Then,  too,  the  use  of  the  terms  "epithelioma" 
and  "carcinoma,"  not  to  mention  the  rest  of  the  nomenclature,  has 
varied  markedly  at  the  hand  of  different  writers,  and  even  today 
there  is  no  uniformity.  The  use  of  the  term  "papilloma"  is  a  splen- 
did illustration  of  this,  for  the  word  is  used  to  cover  almost  any 
tumor  that  projects  at  all  above  the  surface  of  the  skin  or  mucous 
membrane. 

According  to  Unna,-  the  first  division  of  carcinomata  of  the  skin 
was  made  by  Hannover^  in  1852,  when  he  made  use  of  the  termjs 
"flat"  and  "infiltrating,"  a  diA"ision  that  was  brought  into  popu- 


*Virchow:Die    Krankhaften    Geschwiilste,    Berlin,    1S63. 

=  Unna:  Histopathology   of    Diseases    of    the    Skin    (Walker's    translation).    New 
York,   1S96. 

5  Hannover:  Das   Epithelioma,    Leipzig.    1S52. 


IS  SKIN    CANi'iaj. 

larity  in  the  irront  work  ot'  Thiersch'  in  iMi.').  And  yet  ThiiTsch 
ivcoiriiizoil  that  an  ointholial  canciM'  »it"  a  llat  cr  appan-ntlx'  bcniirn 
nature  niiiilit  coiiu'  to  inliltrate  the  tissues  vei-y  (K'eply.  l-'oi-  a  fur- 
ther eritieisni  of  Thiei-seh's  views  the  readier  is  referred  to  i)a<;es 
GG5  to  GGS  of  .I'nna's  hook.  althoU'j:h  it  must  l)e  elea'.-ly  understood 
tliat  the  autlior  l»y  no  means  coincides  with  all  of  I'nna's  beliefs 
and  eritieisins. 

To  some  extent  Thiersch,  and  to  an  e\-en  ijreater  extent  many  suh- 
sotjuent  writers,  haxc  attempted  to  classify  cutaneous  eareinomata 
aeeordinji;  to  the  tissue  from  which  ll)e.\  spran«r.  Thei'e  are,  of 
eoui'se.  the  following  ]>o.ssil)le  coui'ses   for  epitln-lial   tumoi's: 

1.  The  various  layers  of  the  epidei'mis. 

2.  The  hair  follicles. 

3.  The  scbaeeous  jjlands. 

4.  The  sweat  glands, 
f).  The  sweat  dnets. 

6.   C'ontrenitall\'  misplaced  t'pilhelial  structures  oi-  cells. 

Unfortunately  for  this  i)lan,  none  of  its  advoeates  have  been  thor- 
oughly good  pathologists,  and  hence  there  have  been  many  glaring 
errors.  For  instance,  any  carcinoma  with  the  cells  arranged  in  a 
hollow  cylinder  at  once  had  its  (M-igin  ascribed  to  the  sebaceous  glands, 
which  notion,  of  course,  is  an  absolutely  erroneous  one.  For  a  more 
detailed  account  of  these  fallacies  the  reader  is  again  referred  to 
I'lma. 

I'nna's  own  classification  deserves  esjiecial  notice  because  he  is  a 
thoroughly  well-trained  ])athologist,  has  studied  the  question  care- 
fully, and  has  made  an  effort  to  give  a  satisfactory  classifieation. 
An   abridgement   of  his   classification    is  as   follows: 

I.  Malignant  new  for))uilii/ns. 
A.  Carcinoma    vulgare. 

1.  Fungating  forms. 

a.  Fai)illai'y. 

b.  Coarse  reticular. 

2.  Cylindrical  forms. 

a.  Keticulai-. 

b.  Simjde  cylindrical. 

c.  Acinous. 

d.  Styloid. 

<  Thiersch:  Der   Eijithelkrebs,    Leipzig,    18C5. 


(;i;Ni':i{Aii  (;()Xsii)i:kati().\s.  19 

3.  Alvc()];ir    IVtriiis. 

a.  L;ir}4(!  jiJvcoljir. 
I).  Siiuill  alvoolnr. 

4.  ( 'iU'('iii(iiii;ili)iis    lyiii|ili;it  ic    in  l';i  ret  inns. 

a.  ( "arciiioiiia  -Jacob,  i-odciit  ulfor. 

b.  ('jirf'inoiiiM    of  Ihc  sjiiloc's  skin. 

c.  X(M'()(|('i'iii;i    i)i<4ii)('ii1osiiiii. 

<1.  Pajj^ct's  ciU'ciiioiiia,  of  the   iii|i[)lc. 
0.   Ncvo-  and   iiicbiiio-cai-fiiioDiala. 

//.  Botif/u  nvtv  fornidlious. 

A.  Tnmoi's  propei". 

1.  Of  the  epidermis. 

a.  Acanthoma,  including 
Verruca  vulgaris. 
Condyloma. 

Epithelioma    (moUuscum)    contagiosum. 
Acanthosis  nigricans. 

2.  Glandular  hypertrophy  and  adenoma,  including 

a.  Hypertrophy  and  adenoma  of  the  coil  gland  ap- 

paratus. 
General  hypertrophy. 
Spiradenoma. 
Syringoadeuoma. 

b.  Hypertrophy  and  adenoma  of  the  sebaceous  glands. 
Sebaceous  gland  hypertrophy. 
Steadadenoma. 

B.  Stagnatory  tumors. 

1.  Of  the  epidermis. 

a.  Keratoma,  including 
Callus. 

Clavus. 

Cutaneous  horn. 
Angiokeratoma. 
Onychogryphosis. 

b.  Cysts,  including 
Traumatic  epidermis  cysts. 
Follicular  cysts. 

Horny  cysts. 
Sebaceous  cvsts. 


20  SKIN    CAXCKR. 

2.  Syriiigal  cysts. 

a.  Duct  cysts. 

b.  Porous  cysts. 

///.  Malformations. 

A.  Progressive  disturbances  of  liutrition. 

1.  Proliferating  tumors. 

a.  Syringoadenoma  (lymphangioma  tuberosum  multi- 

plex). 

b.  Acanthoma   adcnoidcs  cysticum    (multiple  benign 

cystic  epithelioma). 

2.  Stagnatory  tumors. 

a.  Dci'moids. 

b.  Atheromata. 

Certain  objections  can  at  once  be  raised  to  this  sclicmc.  First, 
there  is  a  mixture  of  clinical  and  pathological  forms.  Second,  it 
treats  of  the  less  important  tumors  according  to  their  origin,  while 
it  totally  ignores  the  origin  of  the  more  important  tumors.  Third, 
it  is  doubtful  if  neoplasms  can  rightly  be  divided  into  "tumors 
proper"  and  "stagnatory  tumors,"  using  the  latter  expression,  in 
Unna's  sense,  to  mean  that  there  is  not  an  undue  proliferation  of 
tissue,  but  rather  a  lessened  destruction  of  it.  Fourth,  Unna  uses 
the  term  "acanthoma"  to  apply  to  the  basal  cells  as  well  as  to  the 
priclde  cells  of  the  rete.  This  is  incorrect,  as  "acanthoma"  should 
apply  only  to  the  hoi'ny  cells;  the  term  "reteoma"  Avould  be  more 
exact  in  many  instances.  Fifth,  nor  can  the  writer  agree  that  the  mul- 
tiple benign  cystic  epithelioma  is  a  malformation,  nor  does  he  be- 
lieve that  it  should  be  called  "acanthoma  adcnoidcs  cysticum,"  for 
the  reason  that  it  develops  from  basal  cells.  With  these  few  excep- 
tions, however,  Unna's  classification  is  excellent,  and  a  model  for 
all  future  attempts. 

Ribbert's^  terminology  is  still  very  popular,  especially  among  clin- 
icians, for  it  has  the  merit  of  simplicity.  According  to  this  author 
we  have: 

Papillomas  which  comprise  fibro-epithelial  tumors. 

Epitheliomas  which  comprise  tumors  derived  from  the  surface  epi- 
thelium. 

Carcinomas  wliioh  comprise  tumors  derived  from  glandular  epi- 
thelium. 


•Rlbbert:  Geschwiil.«tlehre.    Born,    1904. 


GENERAL   CONSIDEKATIONS.  21 

As  Auspitz,  Unna,  and  many  others  have  jx^intcd  out,  the  term 
papilloma  is,  histologically  speaking,  a  grave  misnomer,  for  the  real 
development  is  in  the  rete  and  the  papilla;  arc  only  secondarily  af- 
fected. If  all  tumors  arising  from  squamous  epithelium  arc  to  be 
spoken  of  as  cpithcliomata,  we  must  call  malignant  epithelial  tumors 
of  the  lip,  tongue,  pharynx,  esophagus,  and  of  certain  portions  of 
the  genital  tract,  cpithcliomata.  To  the  author  this  seems  undesir- 
able for  two  reasons;  first,  because  these  tumors  run  the  same  course 
as  the  glandular  careinomata;  and,  secondly,  because  the  term  car- 
cinoma means  more  to  both  physician  and  laity  than  does  the  word 
epithelioma,  especially  since  the  latter  is  sometimes  used  to  desig- 
nate a  benign  growth. 

Krompccher,*'  in  his  excellent  monograph,  "Der  Basalzellenkrebs  " 
adopts  the  following  classifications: 

1.  Fibroepithelioma  spinocellulare  simplex,  or  keratodes. 

2.  Carcinoma  spinocellulare  simplex,  or  keratodes. 

3.  Fibroepithelioma  basocellulare. 

/  Solidum. 

.    ri      •  1  -,-.-.       lAdenoides. 

4.  Carcinoma  basocellulare<' ^ 

\  Cysticum. 

Hyalinicum,  etc. 


0 


Bloodgood,"  after  a  characteristic  thorough  search  of  the  litera- 
ture, advocated  the  following  scheme  in  his  teaching  and  for  his 
specimens : 

1.  Benign  epithelial  warts. 

a.  Mixed  epithelial  warts. 

b.  Spinocellular    (horny)    warts. 

c.  Basocellular  warts. 

2.  Malignant  epithelial  warts. 

a.  Epithelioma  spinocellulare  malignum. 

b.  Epithelioma  basocellulare  malignum. 

3.  Malignant  basocellular  tumors. 

a.  Epithelioma  basocellulare  solidum  malignum. 

b.  Epithelioma  basocellulare  solidum  et  adenoides  malignum. 

c.  Epithelioma   basocellulare    solidum   et    adenoides    cysticum 

malignum. 

d.  Carcinoma  basocellulare   solidum  stellatum. 

4.  Carcinoma  cubocellulare. 


'Krompecher:  Der  Basalzellenkrebs,  Jena,  1903. 
'Bloodgood:  Progressive    INIedicine,    December,    1904. 


11  SKIN    lANli:i{. 

').  Epitlielioma  spinocellulare  inalij^num. 

6.  C'ai'cinoiiia   .si)iiiuci'llulai'e  inaliiriium. 

7.  AtleiuicarciiKtiiia   of   haii'   t'ollicles. 
S.  Adeiioc.-irciiiDina    of  sweat    tilauds. 

Here  the  aiitlinr  scridusly  chjects  to  I  UiukIltooiI  "s  dift'ei'i'iil  iat  ion 
of  malignant  tumors,  haxiiii;-  the  same  ori<>:in.  into  I'pitheliomata  and 
earcinonmta  aecoi-dinji;  to  sli}4:lit  differenci's  in  ilicir  histoloyieal  pic- 
ture. l>lood<;ood  uses  the  term  epithelioma  when  the  gi'owth  has  re- 
tained tlir  picture  of  tlie  tissue  from  wiiich  it  spranji'.  and  carci- 
noma when  the  picture  of  the  original  tissut-  e.iii  nn  JDnger  he  dis- 
tiniruislied.  In  some  tunn)rs  certain  sections  will,  how CNcr.  I'csemhie 
epithelioma,  anil  nthei'  sectiims.  |)erhai>s  mdy  a  shmt  distance  away, 
will  resemble  carcinoma,  antl  hence  this  diiVerentiation  does  not  aj)- 
lieal  to  the  wi-itei-  as  being  ])ractical.  The  spiinx'cllulai'  warts  are 
not  necessarily  linmy  warts;  liei-e  there  seems  to  be  some  confusion 
with  the  kei'atomata.  Othei'wise.  howevei'.  IJloodgood's  ])athological 
classiHcation  is  exti'cnu'ly  good.  In  addition  to  giving  us  a  woi'king 
iliffereiit  iatioii.  liloodgood  lijis  also  shown  exactl\'  how  the  pathology 
of  a  neoi)lasm  agrees  with  its  clinical  course,  and  hence  with  its 
treatnuMit.  lie  has  added  a  most  important  chapter  to  the  study  of 
the   maligmint    cutaneous   tumors. 

In  an  attempt  to  give  a  simpler  classilication.  liloodgood  has  re- 
eently  devi.sed  the  following  classification: 

1.  Heiugn  i)recancerous  lesions. 

a.   Warts,   which   include  any  e])ithelial   h\pert  rophy. 

i).   Subepidermal    nodules,   often  sebaceous  gland    infections. 

c.  I  leers,   as  tul)erculcus.   syphilitic,  etc. 

d.  Sinuses,  unhealed. 

'1.  lOarly  cancers. 

a.  ^lalignant  warts. 
1).   Adein)careiiu)mata. 

e.  Epithelial  hypertropli\'  in   ulcers,  and  sinuses. 

3.  Late  cancel's. 

a.  Spino-celled  oaneers. 

b.  ('ul)o-eelled  cancers. 

c.  Baso-eelle(l   canc(M-s. 

Inasmuch  as  tiiis  book  is  pi-imai'ily  intemled  for  the  clinician,  it 
has  seemed  to  the  author  to  be  l)est  to  give  a  clinical,  rather  than 
a    j)atholouic;d.    nomenclature,    ami    he   has   ado]ite<|    the    following: 


<;|':m:i;ai,  (;(>nsii);;i{\'ii(>.\s.  23 

1.  I>('iii<i'ti  cpitliclinl   liitiioi'S. 

;i,.    K('r;i1oiiiiil;i. 

b.  Mixcd-ci'llcil  ciiit  licli;il   wjirls. 

('.    S|)iii()iis-('('ll('(|   ciiit  licli;il    Wiirts. 

,,     ,         ■   ,     ,•    ,  \  Xc.\oi(|. 

(1.    I>;is()-('cll('(l    ('|)i1  licli.il    tumors    .         ,,•    ,      , 

/  .Mull  Ipic    l)Mll<^ll. 

2.  Malif^iuiiit  ('|)illi('li;il   \v;ii'1s. 

a.  Spiiio-f'cllcd. 
1).   I>as()-('(']1('(1. 

3.  Baso-celled  carciiioinata. 

a.  Flat  rodcMit  iilcci'. 

b.  lUitloii-likc  or  iiodidiii'  cjirciiKdii;!. 
('.  Ixollcd-cdjijc  carcinoin;!. 

d.  Depressed  scar-like  (vii-cinoina. 

e.  Morphea-likc   earciiioina. 

f.  Fungatiiif?  earcinoma. 

g.  ITlcerative  eareinonia. 

4.  C*ubo-eelled  eareiiiomata. 

a.  Ulcerative  carcinoma. 

b.  Fiingating  carcinoma. 

5.  Spino-celled  carcinomata. 

a.  Ulcerative  carcinoma. 

b.  Fungating  carcinoma.  , 
(i.  Tumors  of  hair  follicles. 

a.  Benign   (multiiile  benign  cystic  epithelioma  of  Jariseh). 

b.  Carcinoma. 

7.  Tumors  of  sweat  glands. 

a.  Adenoma. 

b.  Carcinoma. 

8.  Tumors  of  sweat  ducts. 

a.  Adenoma. 

b.  Syringocystadenoma. 

9.  Tumors  of  sebaceous  glands. 

a.  Adenonui  sebaceum. 

b.  Adenoma. 

c.  Adenocarcinoma. 

10.  Nevocarcinomata    (and  multiple  pigmented  carcinomata). 

11.  Paget 's  disease. 

12.  Carcinomata  by  extension. 

13.  Metastatic  carcinomata. 

14.  Carcinomata  en  cuirasse. 

15.  Endotheliomata  capitis. 


24  SKIN    CANCER. 

Some  authors,  notably  Adaiui^  and  Hcrtzler,^  object  to  Krom- 
peeher's  differentiation  of  skin  carcinoniata  into  prickle  and  basal 
cellular  types,  pointing  out  tliat  the  prickle  cells  are  simply  a  dif- 
ferentiation of  the  basal  t-olls,  and  are  not  of  a  different  origin.  But 
to  the  author  this  elassilieation  seems  justified,  for  the  two  types 
of  tumor  run  absolutely  different  clinical  courses — courses  even  more 
distinct  than  the  histological  pictures.  The  basocellular  tumor  is 
usually  of  slow,  or  of  comparatively  slow,  growth,  and  practically 
never  metastasizes,  thus  differing  markedly  from  the  spinous-celled 
tumors,  which  grow  rapidly,  and  usually  form  metastases.  Krom- 
pecher  also  recognizes  a  basocellular  glandular  tumor,  a  neoplasm 
less  malignant  than  the  type  of  adenocarcinoma,  in  wliich  the  cell 
type  is  that  of  the  superficial  epithelial  lining  of  the  ducts.  Blood- 
good  is  inclined  to  agree  witli  Kronipeeher  in  this  assertion. 

STRUCTURE. 

All  neoplasms  consist  of  two  main  elements — the  cells  and  the 
stroma.  As  has  already  been  stated,  the  cells  are  derived  from  the 
various  types  of  epithelial  cells,  and,  Mith  the  exception  of  the  tu- 
mors derived  from  the  sebaceous  glands,  remain  remarkably  true 
to  type  unless  flattened  out  by  pressure.  AVe  can  easily  recognize 
the  basal-celled  and  the  spinous-celled  type,  and,  with  slightly  more 
difficult}',  the  cubocelled  type.  The  cells  from  the  appendages  of 
the  skin  maj'  usually  be  recognized,  although,  of  course,  the  tumors 
originating  from  the  hair  follicles  may  very  soon  come  to  absolutely 
resemble  the  neoplasms  originating  from  the  surface  epithelium. 
The  cell  type  of  the  sebaceous  glands  usually  changes  so  promptly 
that  it  is  impossible  to  prove  that  a  tumor  had  its  origin  in  these 
glands.  This  change  consists  in  a  loss  of  the  fat.  after  which  the 
cell  is  difficult  to  recognize. 

The  criterion  of  malignancy  is  the  breaking  thi-ougli  of  the  basal 
membrane  by  the  epithelial  cells.  This  basal  membrane  normally 
forms  the  limit  of  the  epithelial  cells,  thus  separating  them  from 
the  fibrous  tissue  of  the  corium.  Invasion,  once  the  membrane  is 
ruptured,  may  take  place  in  any  one  of  several  ways,  all  carefully 
studied  by  Unna.  The  cancer  cells  may  invade  practically  en  masse, 
they  may  form  more  or  less  solid  alveoli,  they  may  push  forward  in 
long  alveoli,  or  they  may  branch  out  like  the  branches  of  a  tree, 
or  they  may  invade  singly  or  in  small  groups.  The  mode  of  in- 
vasion depends  on  at  least  two  factors — one  the  inherent  power  of 

•Adami:  Principles  of  Pathology,  New  York,  1908,  i. 
•Hertzler:  Treatise  on  Tumors,  New  York,   1912. 


GENERAL   CONSIDERATIONS.  25 

reproduction  of  the  euiieer  c(;l]s,  Jiiid  tlif;  rjllici-  the  resisting  power 
of  the  invaded  tissue. 

Characteristic  of  cancer  cells  iire  the  atypical  mitotic  figures,  a 
peculiarity  so  j)ronounc(!d  that  sonic  authors  have  Jjcen  inclined  to 
believe  that  the  atypical  power  of  repj'oduction  was  the  cause  of  the 
disease.  It  is  now  usually  believed,  however,  that  irregular  mitosis 
is  an  effect  and  not  a  cause. 

The  degenerations  of  cancer  cells  ha\e  been  carefully  studied  by 
several  investigators,  including  Gilchrist^"  and  Unna.  Both  call  par- 
ticular attention  to  the  close  resemblance  of  some  of  these  degenera- 
tive bodies  to  parasites,  and  warn  against  the  error  of  mistaking 
them  for  causal  organisms. 

Unna  states  that  the  most  connnon  degeneration  is  the  hyaline  one, 
the  so-called  cancer  pearls  being  one  variety  of  this  type  of  degenera- 
tio]x.  The  pearls  are  simply  groups  of  cells  arranged  concentrically, 
and  having  a  great  affinity  for  acid  dyes,  due  to  the  degenerative 
changes.  Unna  also  describes  eight  forms  of  hyaline  degeneration 
of  the  circumscribed  variety.     They  are : 

1.  Eound  balls  of  a  size  varying  from  15  to  20  microns  in  diam- 
eter, and  in  the  interior  of  which  there  exist  the  remains  of  a  nu- 
cleus, always  lying  in  a  cavity. 

2.  Irregular,  long  twisted  bodies  are  fairly  common. 

3.  Small  hyaline  bodies,  having  a  diameter  of  from  7  to  15  mi- 
crons, may  lie  in  a  nuclear  cavity,  but  close  to  the  nucleus. 

4.  The  bodies  described  in  the  last  heading  may  become  elon- 
gated. 

5.  Hyaline  rods  or  tendrils  are  sometimes  found. 

6.  There  may  exist  capsulated  structures  in  which  there  is  a 
well-preserved  nucleus,  lying  in  a  ring-formed  cell  that  has  under- 
gone hyaline  degeneration. 

7.  Flake  or  vesicle-like  hyaline  bodies  Avith  nuclear  cavities  may 
occur. 

8.  And,  lastly,  there  may  exist  hyaline  vesicles  in  which  the  nu- 
clear remains  are  inclosed  by  two  hyaline  capsules. 

There  is  a  final  group  in  which  exist  conglomerations  which  have 
arisen  from  the  compression  and  coalescence  of  the  individual  ele- 
ments. There  is  another  group  of  hyaline  degeneration,  even  com- 
moner than  the  circumscribed  changes,  and  that  is  the  diffuse  hy- 
aline change.     This  degeneration  can  be  distinguished  only  in  well- 


*»  Gilchrist:  Johns  Hopkins   Hospital  Reports;    Studies   in  DermatologA%   1S96. 


2G  SKIX    CANCKR. 

staiu'Ml  siK'ciiiU'Us.  jiml  is  Irciiiu'iitly  a  pi-cciirsdr  ol'  tlir  iiiori'  cii'cum- 
scrihtnl  cluuiiros.  rnna  states  "tho  liiiiitcil.  dilTusi'd  hyaliiio  lU'iron- 
eration  of  tlio  imuT  ix'i'iiuiclcai-  sultstaiicc  of  the  ccll-hody  is  ox- 
traoi\liiiai'il\'   coiinnon." 

Xi'xt  in  fi'eciuoncy  to  the  liyaliiic  (li'Liciu-ratioii  is  tlic  simple  soft- 
eniiii;  and  liquefaction  of  tlie  ei)itlicrnini,  which  is  often  coin])ineil 
with  the  hyaline  changes.  A  sinjxle  cell  may  he  attackeil.  or  a  luv^v 
jiortion  of  the  cancer  may  soften.  This  form  of  deuvnei'ation  is  not 
present  in  those  forms  of  caiuH'r  thai  irrdw  hy  loii^-.  sleii<ler  proc- 
esses. 

A  few  cases  show  keratnid  degenerations;  that  is.  the  formatit)n  of 
true  hoiny  pearls,  so  named  because  of  their  jifross  api)earanee  un- 
(ler  a  lens  of  low  maufnifyiiiir  powei*.  This  foi'm  of  detreneration  oc- 
curs solely  in  tumors  deri\-ed  fi-om  thi'  prickle  layer.  The  cells  arc 
arrangred  conccnti'ically  in  wlmrls.  and  ai-e  apparently  undei-  con- 
siderable i)rcssure.  Naturally  1he.\-  have  a  jjreat  affinity  t'oi'  acid 
dyes,  such  as  eosin  or  orcein. 

Occasionally  calcification  occurs  in  cancer,  dexclopin^^  from  the 
deposits  of  lime  salts  in  the  pearls. 

The  stroma  or  fibrous  tissue  is  either  the  old  fibrous  tissue,  which 
has  been  invaded  by  the  tunu)r  cells,  oi'  is  ncwl>-  formed.  In  some 
t\pes  of  neoplasm  one  prevails,  while  in  other  types  of  tumor  the 
other  ])revails.  Of  course  thei'c  is  frequently  a  combination  of  tlie 
two.  (^uite  frequently  the  cancerous  invasion  of  the  corium  induces 
a  severe  inllanuiiatory  reaction,  some  authors  fioinjjr  so  far  as  to 
claim  that  a  cancerous  downjrrowth  of  tissue  never  occurs  without 
a  C(>llular  exudate  forndny:  around  it.  The  cells  usually  found  arc 
small  i-ound  cells,  fixed  tissue  cells,  mast  cells  and  plasma  cells, 
(iiant  cells  are  occasionally  found.  Sometimes  this  reaction  is  so 
marked  as  to  almost  comi)letely  obscure  the  cancerous  process.  I'n- 
na  states  that  in  twenty-four  out  of  his  seventy'  cases  an  iidlamma- 
tory  reaction  was  very  considerable;  the  rodent  ulcers.  Pajret's  can- 
cers, and  the  cancei-s  of  xeroderma  ])i<rmentosum  in  particular  show- 
injr  much  infilt  raliun.  It  is  veiy  i-are  to  find  ever\'  Oddule  or  i>roc- 
e.ss  of  invadinj;  cancel-  walled  in  by  an  iidlammatory  mend)rane,  but 
some  of  them  usually  ai-e.  Unna  states  that  in  ten  of  his  cases 
there  was  no  inflammatory  reaction.  The  cellular  iidiltration  of  the 
cutis  is  usually  dii-ectly  in  ratio  with  the  rapidity  of  infill  i-ation  by 
the  neoi)lasm. 

Neoplasms  have  a  comi)lete  vasculai'  cii-culalion.  the  blood  ves- 
sels may  pre-exist,  or  may  be  newly  foi-med.  but  are  usually  derived 
from  both  sources.     The  newh-formed  blood  vessels  consist  of  an  en- 


(;i;xi:i;.\L  roNsiDij;  \'rio.\s.  J( 

d()tlK'li;il    liiiiii<^\    willi    (('•ciisioti.illy    ;i    (ibroiis   oiitr't-   hiyor,    Jiri'l    vary 
^'r(';i11y  in   size 

Accoi'diii^-  1o  1 1  ci't/.lcr  ncilhcr  ihtxcs  nor  lyhii»li;if  ifs  liav'f  boon 
,s;i1  isfjiclorily   (Iciiioiisl  r;itc(|. 

GROWTH  OF  TUMORS. 

Many  aiitliors  1hini<  thai  a  carcinoma  sprin^'^s  from  one  ccjitci',  but 
rctoi-Keir.s"  work  would  seem  1o  sliow  tlial  llic  mulliccntric  orif^in 
of  inalifi^nant  opilhclial  tumors  is  far  from  uncommon.  As  I»lood- 
good  well  observes,  I'elei'sen's  (b'moustrations  appix-  to  l!ie  basal- 
ccllcd  type,  a  fonu  of  tumor  tliat  is  frof|noiitly  multiple.  Fetei-seu's 
work  appears  to  have  been  vvvy  carefull\-  done  aftci-  the  "Platteu- 
modcllen-Methodc"  of  l>orn.'-  The  early  tumors  were  cut  into  sc- 
I'ial  sections,  and  from  these  seetions  a  wax  model  was  ])uilt  up.  This 
is,  of  eourse,  the  only  positive  way  in  whieh  the  (juestion  as  to  the 
unieentric  or  inultieentrie  origin  of  cancer  ca]i  be  settled.  As  Ijoar- 
ing  on  this  point,  rxib'hi'ist  has  reeently  had  a  very  early  basal- 
celled  earci)U)nia  of  the  face,  in  whieh.  at  a  distance  of  about  3  mm. 
from  the  main  tumoi-  mass,  there  was  a  distinct  new  and  exceeding- 
ly early  carcinoma  developing.  Serial  sections  showed  that  there 
was  no  connection  between  the  two.  If  these  tumors  are  really  of 
multicentric  origin,  the  point  has  a  great  practical  beai'ing,  foi"  it 
means  that  a  wider  incision  is  necessary  at  the  time  of  operation. 
This  fact,  or  rather  theory,  may  explain  why  basal-celled  carcino- 
mata  so  often  recur  after  operations  in  which  but  a  small  margin 
is  given  them.  On  the  other  hand,  it  must  always  be  remembered 
that  metastases  may  have  taken  place  by  a  lymph  channel,  and  that 
an  apparently  separate  growth  is  in  reality  simply  a  metastasis. 

At  first  it  was  thought  that  cancer  spread  by  a])position.  that  the 
cancer  cell  caused  the  neighboring  cells  to  also  become  cancerous, 
and  later  observation  has  shown  that  to  some  extent  this  belief  is 
correct.  Hertzler  says:  ''In  transplanted  epithelial  tumors  in  ani- 
mals the  connective  tissue  has  been  stimulated  to  sarcoma  forma- 
tion, showing  that  the  power  of  growth  may  be  transmitted  to  other 
kinds  of  tissue.  Still  more  conclusive  are  the  experiments  of  Bor- 
rel  and  Lewin,  in  which  epidermis  was  stimulated  to  the  formation 
of  squamous  epithelioma  by  the  transplantation  of  glandular  tumor 
beneath  it,  showing  that  the  proliferating  stimulus  may  be  conveyed 
by  cells  possessed  of  the  power  of  unlimited  growth.  In  both  these 
instances  there  can  be  no  confusion  between  the  normal   and  the 


"Petersen:  Beitr.  z.   klin.   Chir..   1002.  xxxii.   543. 
'=Born:  Bohm-Oppel    Taschenb.    cl.    Milvr.    Technik..    74. 


28  SKIX    CANCER. 

tumor  cells.  The  proliferation  excited  by  Scharlach  R.  and  Sudan 
111.  likewise  show  clearly  that  epithelial  cells  can  be  made  to  pro- 
liferate and  invade  surrounding  tissue  by  the  action  of  certain  ex- 
trinsic stimuli.  It  may  be  regarded  as  proven,  therefore,  that  nor- 
mal epithelial  cells,  under  certain  conditions,  may  be  made  to  pro- 
liferate by  close  contact  with  malignant  cells  or  by  other  stimula- 
tion." And  yet  it  is  generally  conceded  that  tumor  growth  comes 
from  the  multiplication  of  the  tumor  cells,  rather  than  from  the 
conversion  of  other  cells  to  a  malignant  type. 

Gro^vth  takes  place  by  the  cancer  cells  either  invading  between 
the  connective  tissue  fibers  through  the  lymphatics  or  otherwise,  or 
by  bodily  pushing  the  connective  tissue  aside,  or  more  usually  by  a 
combination  of  both  methods.  These  invading  cells  may  or  may  not 
retain  connection  with  the  main  body  of  the  tumor.  In  the  more 
malignant  types  of  tumors,  cells  may  escape  to  the  lymphatic  glands, 
or  may  be  carried  by  blood  vessels  to  remote  portions  of  the  body, 
or  they  may  spread  out  and  form  separate  masses  in  the  proximity 
of  the  parent  neoplasm.  In  cancer  the  growth  usually  takes  place 
through  the  lymph  spaces  and  lymph  vessels.  On  account  of  this 
spread  through  the  Ijmphatic  system,  it  is  often  impossible  to  dif- 
ferentiate between  metastasis  and  local  infiltrative  growth ;  in  fact, 
it  is  desirable  not  to  attempt  to  distinguish  between  them,  for  they 
are  essentially  the  same.  The  superficial  spread  may  be  so  great  as 
to  form  cancer  en  cuirassc,  where  practically  the  whole  subcutaneous 
tissue  becomes  cancerous.  The  lymph  glands  affected  are  usually  the 
nearest  glands  draining  the  cancerous  area,  but  rarely  these  are 
skipped  and  more  remote  ones  are  involved.  Extension  by  contact 
is  rarely  seen  in  tumoi'S  of  the  skin,  and  many  excellent  clinicians 
deny  its  existence.  It  is  very  important  to  note  that  cancer  cells 
may  lie  dormant  for  many  years,  and  then  suddenly  take  on  great 
activity.  AVe  no  longer  speak  of  cancer  patients  as  cured  when  an 
intcr\al  of  three  years  has  elapsed  without  recurrence. 

Occasionall}'  adenomata  of  the  su])i-aronal  or  thyroid  glands  form 
metastases,  and  the  author  has  observed  one  case  Avhere  a  histologi- 
cally benign  adenoma  of  the  sweat  glands  metastasized  to  the  neigh- 
boring glands.  It  seems  reasonable,  however,  to  suppose  that  there 
are  true  area  of  malignancy  in  these  neoplasms. 

Recurrence  after  operation  depends  on  the  factors  already  dis- 
cussed. Recurrence  means  that  all  tumor  cells  were  not  removed  by 
the  surgeon,  either  because  they  had  escaped  to  other  organs,  or 
because  of  a  wide  local  spread. 


(;kni;ral  considkrations.  29 


TOXINS. 


It  has  not  been  proven  that  epithelial  tumors  have  a  specific  toxin. 
What  absorption  there  is  probably  comes  from  the  endotoxins  of 
bacteria  which  are  secondary  invaders. 

IMMUNITY. 

There  is  probably  ]io  authentic  instance  where  an  epithelial  neo- 
plasm, microscopically  proven  to  be  malignant,  has  spontaneously 
healed,  mid  failed  io  recur.  The  central  x>ortion  of  a  rodent  ulcer 
may  heal  and  form  scar  tissue,  and  may  likewise  scab  over  and  ap- 
parently heal  for  a  year  or  even  more,  but  not  permanently ;  in  fact, 
we  know  nothing  of  true  iiiiiiinnity. 

ETIOLOGY. 

The  causative  factor  in  cancer  of  the  skin  is  that  of  cancer  in  any 
other  portion  of  the  body,  and  is  still  unsolved.  Dermatologists  have 
not  done  their  share  toward  the  elucidation  of  the  carcinoma  rid- 
dle, although  they  have  had  better  opportunities  than  any  other  type 
of  clinician,  inasmuch  as  they  are  sometimes  able  to  trace  the  de- 
velopment of  cutaneous  cancer  from  the  various  precancerous  der- 
matoses, of  which  xeroderma  pigmentosum  forms  such  a  beautiful  ex- 
ample. Ewing^"'  has  recently  treated  exhaustively  of  the  different 
theories  as  to  the  etiology  of  cancer,  and  Loeb^'*  has  published  a  num- 
ber of  excellent  papers. 

Cohnheim's  Theory. — Cohnheim^^  believed  that  cancer  arose 
from  congenitally  displaced  epithelium,  beginning  to  grow  riotous- 
ly. As  Unna  has  well  pointed  out,  this  certainly  takes  place  in  the 
neoplasms  arising  from  congenital  moles  and  from  other  nevi.  At 
least  three  objections  may,  however,  be  placed  against  this  theory — 
first,  that  cancer  often  starts  where  no  congenital  rests  can  be  dem- 
onstrated, and  w^here  it  is  extremely  improbable  that  any  such  rests 
would  exist;  second,  that  the  theory  does  not  explain  why  the  rests 
become  malignant ;  and,  third,  as  pointed  out  by  "Welch,  that  even 
in  very  deep  burns,  where  all  of  the  surface  epithelium  is  destroyed, 
a  carcinoma  may  later  develop.  It  may  be  added  that  the  known 
congenital  malformations  do  not  very  frequently  become  malignant. 

Changes  in  Cell  Type  or  Metaplasia.— AYhile  an  epithelial  cell 
of  one  type  may  be  changed  into  an  epithelial  cell  of  another  type. 


"  Ewing:  Arch.  Int.  Med.,  1908,  i,  175. 

^*  Loeb  and   Sweek:  Jour.   Med.   Research,   1913,   xxiii,   2,   July. 

"Cohnheim:  Vorlesungen    liber   allg.    Pathologie,    Berlin.    1S77, 


30  SKIN    (ANCKK. 

there  is  no  proof  that  one  type  of  eell  may  liirn  into  a  i-adically 
different  type.  It  seems  certain  that  metaphisia  in  ejiithelial  tu- 
mors is  conHiieil  within  narrow  limits.  Of  course,  it  is  known  that 
a  benifjn  jJapiMoma.  so-ealled.  that  has  exi.sted  foi-  yeai's  may  later 
beeome  maliijnant.  But.  a<;ain.  this  theory  is  not  satisfyiii'r.  for  it 
jrives  no  explanation  why  these  ehan«res  take   place. 

Regression.  1\\  tiiis  term  Rihhcrt  indicated  a  condition  of  eell 
chancre  where  cells  hecoine  atavistic.  (»r  less  differentiated.  It  is  };en- 
erally  stated  by  path(»lo»rists  that  tumors  arisinj^  from  the  less  dif- 
ferentiated cells  and  showing'  the  structure  i>f  the  jtrimitive  cells  are 
the  most  mali^Miant.  and  yet  in  carcinoma  of  the  skin  we  find  that 
the  basal-celled  (or  primary''  tumors  are  much  less  malijxnant  than 
the  tumors  ai-isin*^'  from  the  jirickle  cells  and  to  some  extent  retain- 
ing; their  structure.  It  is  true  that  in  the  latter  the  jirickles  art- 
short,  or  entirely  lost,  and  that  the  cells  are  .smaller  than  normal. 
but  these  ehanjjes  ma\-  lai-y:cly  be  due  to  i)i'essui'e. 

Atypical  mit(»tic  fi«rures  have  been  studied  by  many,  and  by  .some 
believed  to  l)e  responsible  for  the  abnormal  proliferation  of  the  cells. 
l)ut  the  majority  of  pathojofjists  believe  that  these  abnormalities  are 
the  result  and  not  tlie  cause  of  bewildered  «rrowths. 

Changes  in  Tissue  Balance. — Thiersch  held  that  in  carcinomata 
the  i»rimai\\-  chan^fc  was  in  the  connective  tissue,  that  there  was  a 
weakeniuf?  of  it  which  allowed  the  epithelial  cells  to  expand  and 
penetrate  into  it.  He  thought  that  there  was  an  antagonism  between 
the  epithelial  cells  and  the  connective  tissue  cells,  a  totally  unjusti- 
fied assumption.  It  is  well  known  that  in  many  conditions,  as  in  x- 
ray  cancer,  the  primary  change  is  in  the  connective  tissue,  but  there 
are  no  facts  to  ju.stify  the  belief  of  Thiersch.  Ilertzler  has  shown 
that  in  very  early  eases  of  cancer  the  connective  tissue  does  not  take 
acid  stains  in  a  normal  way,  but  nothing  practical  has  developed  out 
of  this  interesting  demon.stration. 

Microorganisms.— Ewing  gives  the  following  list  of  parasites  that 
have  at  some  time  been  held  to  be  responsible  for  cancer: 

Bactkria. — Bacillus  of  Rappin,  1886;  Scheui-len.  1887:  Franckc. 
1888;  Lampiasi.  1888;  Koubassof,  1889;  Micrococcus  ncofoi-mans. 
Doyen,  1902. 

CocciDiA. — Cocidium  of  Dariei-.  1889;  Albarran,  1889;  Thoma, 
1889;  Sjobring.  1890;  Coecidium  sarcolytuni,  Adamkiewicz,  1892; 
Soudakiewitsch-Metchnikoff,  1892;  Monsarrat,  1905. 

Sporozoa  (unclassified). — Bii'dscye  inclusion,  Foa,  1891;  Plim- 
mer's  bodies.  1892;  Sporozoiin.  Ruffer,  1892;  Sawtschenko,  1893; 
Ameba-sporidium,    Pfeiffer.    1893;    Rhopalocephalus  canceromatosus. 


(;i;ni;k.\l  coxsihKKA'iioNs.  :jl 

KoroliicfC.  In!)-!:  S[)()r()/,(»(iii.  Koui'lofC,  ls;)4;  Bosc.  1807;  llomato- 
zo(")ii,  l\;ili;inc,  IM)4:  ( ';iiicri;iiiicl)a  iiificroj^losHa,  Hiscii.  1000;  Lcy- 
(lriii;i  j4ciiiiiii|);ir;i,  S('li;iiiiiiiiii.  lsO(i:  Intranuclear  parasite,  Schuller. 
1 001 -I. 

Hi,  AS'i'().MV(K'ii;s. — Sjiccliaromvccs  ncolDriiKtns,  Saiifelicc.  1806  : 
PliiHiiKM-,  Leopold;  Roiu-ali,  F>ra  ;  Kusscli's  fuehsin  ho<lies:  MiK-or 
I'jK'ciiiosus,  Scliiiiidl.    lOOIi. 

MvcKTozoA. —  Plasiiiodiophoi'a  bras.sica',  Hehla,  Podwyssoski.  Fciii- 
hcv^,  (Jaylord.  Robertson  and  Wade. 

Spirochkt/E. — Gaylord,  Calkins,  1907;  Cyanid-fast  bodies,  Rob- 
ei-tson.  1007. 

This  list  is  of  spceial  value  as  showing  two  thinj;s — first,  the  enor- 
mous amount  of  woi'k  that  has  been  devoted  to  the  sul).jeet,  and,  sec- 
ond, the  fi'ailtics  of  human  judjjrnient.  Praetically  none  of  these  men 
published  their  results  until  they  were  sure  that  they  had  confirmed 
them,  and  many  had  the  advice  of  distincrui.shed  protozoologi.sts. 
From  all  of  these  results  there  has  come  only  one  thing  of  value — 
namely,  a  healthy  skepticism  on  the  part  of  other  workers.  Almost, 
however,  this  identical  situation  held  for  syphilis  until  Schaudinn 
and  Hoffman  demonstrated  its  cause  only  a  few  years  ago.  and  it  is 
by  no  means  inconceivable  that  some  modern  Pasteur  will  prove  to 
us  that  cancer  is  a  disease  that  is  caused  by  a  micro-organism. 

Contagiousness. — There  are  certain  factors  that  speak  for  the 
fact  that  cancer  may  be  more  or  less  contagious.     These  facts  are: 

Cancer  of  the  thyroid  gland  is  probably  epidermic  in  the  fish  of 
certain  hatcheries.  Recent  articles  stating  that  these  were  not  true 
cancer,  but  only  adenomata,  refer  merely  to  local  conditions  in  cer- 
tain hatcheries.  It  must,  however,  be  admitted  that  a  systematic 
investigation  should  again  be  made  in  order  to  settle  this  point  def- 
initely. 

Cancer  seems  to  be  more  prevalent  in  certain  localities  than  in 
others;  in  some  it  has  been  almost  endemic  for  a  certain  length  of 
time. 

Nurses  who  have  nursed  cancerous  patients  for  a  number  of  years. 
whether  or  not  they  are  related  to  the  victim,  seem  to  be  especially 
liable  to  suffer  from  cancer. 

Cancer  is  certainly  inoculable.  though  usually  within  very  narrow 
limits;  mouse  cancer  is  not  inoculable  from  a  white  mouse  to  a  gray 
one,  so  it  would  be  unreasonable  to  expect  human  cancer  to  be  in- 
oculable to  the  lower  animals.  Again,  this  condition  is  somewhat 
similar  to  that  pertaining  in  syphilis. 


32  SKIN    CANCER. 

Sarcoma  can  be  transmitted  by  a  filterable  virus  according  to  a 
late  publication  by  Rous  and  Mm-phy.^'^ 

In  transplanted  epithelial  tumors  in  animals  tlic  connective  tis- 
sue has  been  stimulated  to  neoplastic  formation,  as  already  men- 
tioned earlier  in  this  chapter. 

Carcinoma  or  sarcoma  usually  develop  at  points  of  lowered  re- 
sistance, so  often  spoken  of  in  dermatology  as  precancerous  derma- 
toses. 

^lalignant  neoplasms  in  plants  may  be  due  to  the  Bacterium  tume- 
faciens,  according  to  the  recently  published  researches  of  Erwin 
Smith. ^"     This  seems  to  be  the  most  definite  work  so  far  published. 

And  yet  it  must  be  admitted  that  cancer  of  the  penis  has  never 
been  proven  to  cause  cancer  of  the  uterus  in  the  wife  of  a  patient, 
nor  has  cancer  of  the  lip  ever  been  shown  to  cause  another  cancer. 

INCIDENTAL  FACTORS. 

Age. — Cancer  of  the  skin  usually  occurs  in  those  mcII  past  mid- 
dle life. 

Sex. — The  two  sexes  are  almost  equally  all'ected,  except  in  can- 
cer of  the  mouth,  which  is  very  rare  in  women. 

Race. — The  native  American  Indian  i-ai-ely  suffers  from  cancer 
of  the  skin.  The  negro  only  exceptionally  suffers  from  basal-celled 
cancer,  but  does  have  the  spinocelled  type  about  as  frequently  as  the 
white  man.  In  the  fifteen  cases  of  cancer  of  the  skin  and  mucous 
membrane  that  the  author  has  recently  seen  among  negroes  there 
was  but  one  rodent  ulcer;  all  of  the  other  lesions  Avere  microscopical- 
ly proven  to  be  of  a  more  virulent  type.  The  lymphomata  are  like- 
wise rare. 

The  multiple,  idiopathic,  hemorrhagic  sarcoma  of  Kaposi  is  most 
frequent  in  Hebrews. 

Heredity. — Judging  fi-om  clinical  data  alone,  heredity  seems  to 
play  no  part  in  the  production  of  cancer  of  the  skin.  Some  of  the 
multiple  benign  growths  are,  however,  often  found  in  members  of 
the  same  family. 

It  would  be  highly  improper  in  dealing  with  cancer  not  to  speak 
of  the  important  work  done  by  Maud  Slye.^^  She  has  shown  that 
in  mice  the  tendency  to  develop  cancer  is  transmitted  from  genera- 
tion to  generation  in  exact  accord  with  the  laws  of  heredity,  so  that 


"Rous  and  ^lurphy:  Jour.  Exp.  Med.,  1913,  xvii,  219. 
»•  Smith:  Wa.shington  Med.  Annal.s,  1913,  xii,  1. 
"Slye:  Jour.  Med.  Re-search,  1914.  1915. 


(ji'iNi'irtAiv  (;()Nsii)i:ka'iio.\s.  33 

it  can  ])('.  l)r('(|  in  niid  oiil-  of  slrjiins  of  mice  ;it  will.  It  is  iiol,  can- 
cer itself  tfiat  is  tr;uisiiii11c<l,  hiif  llic  IciKlniicy  oi:  llif.  fdls  If)  y)ro- 
ducc  cancer  under  siiii;il)l<'  condil  ions.  She  states:  '"'I'lif'  elimina- 
tioii.,  ;is  far  as  possible,  ol'  all  fornis  of  ovcrirrilalion  of  llie  tissues 
of  an  ijxlividnal  of  high  cancer  ancfjstiy  should  j^o  far  to  eliminate 
the  provocation  of  cancer;  and  Ihc  eugenic  control  of  matings,  so 
that  cancer  shall  at  least  JH)t  l)(;  polcniial  on  hof  h  sides  of  ihe  hybrid 
cross,  ought  to  event uale  in  a,  eonsiclerahle  deci'case  in  th(!  frequency 
of  hunnm  cancer." 

Trauma.' — By  ti"unna,  is  meant  not  so  ninch  one  injnr\'  as  a 
chronic  irritation  or  a  scries  of  injuries.  Cancer  of  the  skin  is  very 
apt  to  originate  in  a  spot  that  has  been  more  or  less  continuously 
subjected  to  irritation,  or  upon  an  abnormal  part  of  the  skin,  such 
as  a  wart  or  mole.  The  melanotic  carcinomata  spring  from  con- 
genital, or  more  rarely  acquired,  moles  that  have  been  irritated.  The 
more  malignant  types  of  cutaneous  carcinomata  are  apt  to  spring 
from  the  scars  of  old  burns,  or  of  some  preexisting  dermatosis. 

Lig'ht. — Ilj'de^^  has  clearly  shown  that  those  who  ai-e  the  most 
€xi)osed  to  sunlight  are  the  most  apt  to  suffer  from  basal-celled  car- 
cinomata, the  malignant  growth  usually  being  preceded  by  a  kera- 
tosis. More  recently  Lawrence-"  has  called  attention  to  the  prev- 
alence of  keratoses  and  cancer  in  the  dry  and  sunny  regions  of 
Australia,  and  entirely  independently  reaches  the  same  conclusions 
as  does  Hyde.  It  is  a  well-known  fact  that  in  xeroderma  pigmentosum 
the  lesions  are  made  much  worse  bj^  exposure  to  the  actinic  rays  of 
the  sun.  Unna  has  described  a  condition  known  as  ''sailor's  skin," 
in  which  seamen  more  especially,  but  also  those  exposed  to  much 
light,  suffer  from  multiple  cancers  of  the  more  benign  variety.  Of 
course,  cancer  is  especially  apt  to  develop  upon  chronic  x-ray  der- 
matoses. It  may  be  clearly  stated,  therefore,  that  exposure  to  actinic 
rays  certainly  leads  to  the  formation  of  cancer  of  the  skin. 

Occupation. — Schamberg-^  has  recently  contributed  an  excellent 
chapter  to  the  subject  of  cancer  due  to  certain  occupations,  espe- 
cially chimney  sweeps,  and  paraffin  and  tar  workei's.  These  sub- 
stances undoubtedly  cause  keratoses  upon  the  skin,  and  these  kera- 
toses may  later  become  malignant.  In  addition  to  reporting  several 
cases  of  his  own,  Schamberg  has  thoroughly  reviewed  the  literature 
and  collected  all  of  the  reported  cases.  It  would  seem  that  cancer, 
usually   of  a  mild  form,   is   very   common  among   those   forced   to 

^^Hyde:  Amer.   Jour.   Med.   Scien.,   1906,   cxxxi,   1. 

="  Lawrence :  Trans,  of  7th  Internat.  Congr.  Derm,  and  Syph.,  Rome,  1912,  1219. 

"  Schamberg:  Jour.   Cut.   Dis.,   1910,   xxviii,   644. 


34  >^K1X    CANCKR. 

liaiidli'  the  crude  tar.  ami  tliat  in  iicai-ly  every  factory  a  imniber 
of  cases  can  be  found.  The  lesions  are  usually  situated  \ipou  the 
hands,  and  are  associated  with  a  marked  folliculitis.  In  chimney 
sweeps  the  disease  j?enerall\"  appears  ujion  the  scniluiii.  i]nc  to  the 
collection  of  the  soot  in  the  skin  ru<ra'  in  this  i-ejifion.  and.  while  at 
lirst  com|)arativcly  henijin,  yet  (iuit(>  fre(iuently  leads  to  death,  ('aii- 
cer  is  also  re]ioi1ed  in  ^actlenei's  who  handle  soot  in  the  course  of 
their  work. 

The  etiology  of  cancer  of  the  sl^in  is  still  siih  judici.  hut  ^\"e  <lo 
know  that  cancer  fi'e(iuenlly  dexclops  uiioii  keratoses  caused  hy  va- 
rious external  iri'itants,  such  as  tai-.  lij,dit,  or  the  intei-nal  adminis- 
tration of  arsenic.  Also,  cancer  is  ai>t  to  devcloi)  u])on  othei-  lesions 
of  the  skin,  these  being  fully  considered  in  the  next  chapter.  The 
work  of  Smith  in  showinfij  that  a  disease  in  i)lants  that  is  certainly 
analogous  to  cancer  is  due  to  bacteria,  the  work  of  Rous  and  ]\Iuri)hy 
in  demonstrating  that  chicken  sarcoma  can  be  inoculated  from  a 
tiltrate  passed  through  a  Berkfelt  filtei-.  Khi-lich's'-'-  demonstrations 
that  mouse  cancer  is  rendered  more  virulent  by  being  transmitted 
through  several  generations,  and  Gaylord's"  experiences  with  in- 
fected cages,  not  to  mention  certain  of  Behla's-*  statistics,  would 
seem  to  show  that  cancer  is  probably  due  to  an  infecting  organism 
of  some  sort.  It  is  well  known  that  a  riotous  proliferation  of  cells 
can  be  caused  by  external  irritants,  and  the  fact  that  cancer  so  fre- 
quently develops  upon  the  site  of  an  old  injury  or  of  a  more  re- 
cent break  in  the  skin  may  simply  mean  that  here  is  the  chance 
for  the  infecting  organism  to  gain  foothold.  The  long  periods  of 
latency  before  a  metastasis  manifests  itself  is  certainly  in  harmony 
with  this  theory.  Against  it  speaks  strongly  the  rarity  of  "cancer 
a  deux." 

=  Ehrlich:  Zeit.schr.   f.   Aerztl.   Fortbikl.,   1906,  7. 
"Gaylord:  Jour.  Am.  Med.  A.ssn.,   1907,  xlviii,   15. 
^Behla:  Deut.    n.ed.    VVchn.schr.,    1901,   xxvii,    427. 


CUAVTKli   II. 

rJih]CANCKIi(JlJS    DKRAIATOSHS. 

As  Bowcn'  states  in  u  rofeiit  urticlo,  various  kcraloscH  form  Iho 
commonest  cutaneous  lesions  that  become  caiicei'ous.  Certain  of  the 
soft  nevi,  however,  especially  the  common  pif^menlcd  moles,  and 
scars  resulting  from  var-iims  causes,  either  infectious  or  Iraumatic, 
arc  apt  to  l)ecome  the  seats  of  epithelial  tiuuors,  oflcii  of  an  ex- 
tremely malignant  nature. 

PIGMENTED  MOLES. 

For  nuuiy  ycai's  it  has  been  well  known  l)y  dei'inatologists,  and  to 
a  somewhat  lesser  extent  by  sui'geons,  that  the  most  virulent  form 
of  skin  cancer  (or  sarcoma) — namely,  the  melanotic — always  has  its 
origin  in  either  congenital  or  acquired  pigmented  moles.  In  1903, 
Bloocigood,-  and  a  few  months  later  Keen,"  two  eminent  American 
surgeons,  showed  how  frequent  and  fatal  these  growths  were.  They 
further  stated  that  not  only  all  acquired  moles,  but  all  congenital 
moles,  that  began  to  grow,  that  showed  any  signs  of  ulceration,  or 
that  were  subject  to  continuous  irritation,  should  be  removed  as  a 
prophylactic  measure.  Unfortunately,  although  this  point  is  now 
conceded  by  all  surgeons  and  dermatologists,  neither  the  profession 
at  large  nor  the  general  public  is  as  yet  educated  up  to  it,  but  there 
are  many  signs  of  an  awakening. 

Neither  the  large  raised,  hairy  moles,  nor  the  small  hairy  ones, 
are  apt  to  develop  into  melanotic  growths,  and  only  rarely  do  they 
become  the  seat  of  basal-celled  cancers.  The  almost  flat,  deeply  pig- 
mented, common  moles  are  the  dangerous  ones. 

Histology. — Histologically,  these  benign  growths  consist  of  more 
or  less  epithelial  hj^pertrophy ;  beneath  the  rete  there  is  a  thin  layer 
of  normal  corium,  and  then  come  the  characteristic  large  nevoid  cells, 
closely  grouped  together,  as  shown  in  Fig.  1.  Some  of  the  pigment 
is  in  these  cells,  but  may  also  occur  in  the  neighboring  corium.  There 
is  considerable  discussion  as  to  whether  these  cells  are  of  mesoblas- 
tic  or  epithelial  origin,  the  weight  of  evidence  seeming  to  favor  the 
latter  view.  This  question  will  be  fully  discussed  in  the  chapter 
devoted  to  the  malignant  melanotic  gro"s^i:hs. 


^Bowen:  Jour.  Cutan.  Dis.,  1912,  xxix,  241. 
^Bloodgood:  Progressive   Medicine,    Dec,    1903,    149. 
'  Keen:  Jour.  Amer.  Med.   Assn.,   1903. 


3G 


;K1N    C'ANCKR. 


Fig.  1. — In  this  pliotoiniernKiaiih  ^<i  an  urdiiiaiy  iii>;iiR'iiu-il  luuK-  may  bo  seen  the 
masses  of  nevoid  cells  eontainiiig  pigment,  and  also  pigment  scattered  through- 
out the  neighboring  corium.  There  is  a  layer  of  normal  corium  between  the 
rete  and  the  underlying  masses  of  cells.     (Author's  collection.) 

Malignant  Degeneration. — The  liisl  clinical  eviclcut'os  of  nialij?- 
naney  are  often  ^■cry  slight ;  tliere  may  be  a  slight  growth  or  a  slight 
ulceration,  i)ossibly  followed  by  the  development  of  a  tnmor   (Fig. 


Fig.  2. — The  patient  shown  in  this  illustration  had  a  common  mole  of  the  neck, 
which  he  irritated  while  shaving.  It  was  removed  under  local  anesthesia,  and 
promptly  recurred  with  the  result  shown.  There  were  many  other  growths 
both  in  the  skin  and  glands.      (Heidingsfeld's  collection.) 


PUKCANCKKOIJS    I)i;i{M A'I'OSKS.  -H 

2),  but  the  C()ii<li1  loii  lo  he  (lrc;i(|c(|  is  llic  woiKlcrfiilly  r;ipi(|  fVtrMia- 
tioiL  of  mcta.stu.scs,  cither  in  llic  skin  or  in  llic  •^'■hinds  or  visoora. 
Metastasis  may  take  phicc  before  ;iny  elmn^c  is  nolcd  in  ihc;  rnolc. 
Bloodf^ood  states  that  llic  firsi  [i;il  liolo<^ic;il  c\i(|ciicc  of  iriali(^ancy 
is  to  be  found  in  the  ijivasioji.  of  Ili<'  coriiini  Just  I)ciica1b  the  )-etc, 
and  above  the  nevus,  by  nevoid  cells. 

Treatment. —  When  it  is  (leemed  ;id\is;ible  lo  remove  a  mole,  it 
may  be  done  by  any  one  of  several  melliods.  JOntjriiaii''  and  I^evan"' 
state  that  the  actual  cautery  shouhl  alwjiys  be  used,  believing  that 
the  use  of  the  knife  or  of  caustics  favoi's  the  dissemination  of  can- 
cer cells.  Bloodfj;ood/'  however,  advocates  the  knife,  stating  that  dis- 
semination is  always  so  rapid  that  the  above  ci-iticisms  are  not  per- 
tinent. Personally,  the  author  believes  that  when  it  is  suspected 
that  malignant  change  has  taken  place,  or  is  about  to  take  place, 
the  cautery  should  be  used,  but  that  in  removing  a  mole  for  prophy- 
lactic purposes  the  electric  needle  wall  suffice.  Bloodgood  states  that 
he  has  excised  a  number  of  moles  that  have  been  treated  with  car- 
bon dioxid  snow  by  capable  dermatologists,  and  that  all  of  the  nevoid 
cells  were  not  destroyed,  and  hence  he  cannot  recommend  this  method. 

SEBORRHEIC  WARTS. 

Clinical  Course. — These  lesions,  also  called  senile  Avarts  and  seb- 
orrheic nevi,  are  very  common  on  the  backs  and  faces  of  elderly 
persons.  Upon  the  face  they  usually  develop  upon  the  temples,  or 
sides  of  the  face,  or  near  the  midline,  especially  upon  the  nose.  They 
develop  slowly,  first  appearing  as  minute  yellowish,  somcAvhat  scaly, 
patches,  usually  roughly  oval  in  shape,  and  varying  in  length  from 
2  to  20  mm.  A  little  later  the  follicular  openings  can  be  recognized 
as  black  spots,  and  still  later  there  is  the  development  of  a  thick, 
closely  adherent  black  scale.  At  first  the  lesions  are  but  little  ele- 
vated above  the  skin  level,  but  later  become  distinctly  so.  Itching 
is  rare.  The  later  course  has  been  recently  carefully  studied  by  Sut- 
ton." He  concludes  that  there  are  three  types  of  advanced  lesions — - 
namely,  the  keratotic,  the  nevoid,  and  the  verrucose.  The  keratoid 
is  usually  small  and  is  covered  with  a  hard,  dark  crust.  The  nevoid 
approaches  the  type  described  by  Unna,  and  appears  as  a  soft,  yel- 
lowish lesion,  with  but  little  horny  thickening,  while  the  verrucose 
lesions  haA'e  a  thin.  A'ellowish  crust,  Avliich  when  removed  shows  a 


^  Engman  and  Buhman:  Medical  Herald,   1913,   277. 

°Bevan:  Quoted  by  Bloodgood,   Progressive  Medicine,   Dec,   1904,   175. 

« Bloodgood:  Progressive  Medicine,  Dec,  1904,   175. 

"  Sutton:  Jour.    Amer.    Med.    Assn.,    1915. 


38 


SKIN    CANCER. 


distinctly   warty  or  vcrrucoso  cDiulition  IxMU'jitli.     Noiu'  of  these  le- 
sions disappear  spontaneously. 

Pathology. — Ilistolojjieally,  these  lesions  lia\t'  heen  studied  1)\' 
Pollitzer,*^  Unna,^  Hartzoll,'"  Fordyce,"  Sutton  and  others.  The  fol- 
lowinji^  aeeount  is  taken  l"i-oni  Sutton's  deseription.  The  keratoid 
variety  is  eharaeterized  by  j^reat  corneus  hy|)ertrophy,  sonic  para- 
keratosis, a  moderate  de^yree  of  acanthosis,  sliiihl  piolil'ei'ative  changes 
in  the  prerniinal  layei'.  with  some  llatteniim  d'  ihc   iiapillary  bodies. 


Fig.   3. — This   illu.straliuii  ;sliuws  a   I'un^^ous  cancel-,   whifli   .sprang  from   a   seborrheic 
keratosis,   similar  to  the  ones  upon   the  cheek  and   nose.      (Sutton's   collection.) 


The  sweat  ducts  arc  dilated  and  cy.sts  may  be  formed.  The  se- 
baceous glands  are  normal,  but  contain  much  free  fat.  The  blood 
vessels  of  the  corium  are  dilated,  and  there  is  some  infiltration  of 
the  subpa])illary  ])ortion,  "with  small  round  and  fixed  tissue  cells. 

The  nevoid  type  showed  changes  similai-  to  those  described  by  I^n- 
na  in  his  "nevus  seborrheoicus" — that  is.  ])ut  little  change  in  the 
epithelium,  although  there  is  some  slight  parakei-atosis,  but  a  marked 


"  Pollitzer:  Monat.shefte   f.   prakt.   Dermat.,    ISDO,   xi,    145. 
"Unna:  Histopathology  of   the   Skin    (Walkir's    translation). 
"Hartzell:  Jour.   Cutan.   Dis.,   lOO.'i. 
"Fordyce:  .lour.    Amer.    Med.   Assn..    1010,    Iv,    1624. 


I'RiocANCiatocs  i)i':i{,MA'r()si;.s.  •>') 

increase  of  pif^-nieiitntioii  in  the  denn;!,  loj^'flliec  willi  dilaljilion  of 
the  blood  vessels,  Jind  a  heavy  infill  r;i1(!,  wilh  round  ov  \)(i\yir<i\iii\ 
cells  that  resemble  nevoid  cells.  The  <4l;indiil;ir  clciiifnls  ;i  re  hnl  lit- 
tle altered. 

''i'he  vcrrucose  form  is  dist  in^uislic<|  by  (•onsidcr;d)lf  liyjtei'aUora- 
tosis,  very  pronounced  jicanlliosis,  acti\c  prolircijii  i\c  changes  in  the 
germinal  layer  and  also  at  times  in  other  portions  of  the  rete,  and 
most  especially  by  grejit  |)apillary  hyix-rtrophy.  The  cutis  shows 
changes  of  a  subacute  in  (hi  minatory  natni'e. 

Malignant  Degeneration,  lijis.d-ccllcd  cjmcers  ai-e  very  ])r<jne  to 
develop  ui)on.  these  lesions  wluiii  tlu^y  ai'e  situated  ui)on  the  face, 
and  occasionally  a  i)i'ickle-cell(Ml  cfiiicei'  develops  in  this  situation. 
When  these  lesions  develo])  upon  the  b;inds,  prickle-celled  cancer  is 
a  common  result.  The  first  malignant  change  noted  is  a  slight  ul- 
ceration, accompanied  by  a  serous  discharge.  This  ulcei'ation  slow- 
ly spreads  and  there  is  an  increase  in  the  indui-ation.  Jt  is  highly 
probable  that  nearly  five  percent  of  all  these  keratoses,  especially 
those  of  the  keratoid  variety,  terminate  in  carcinoma. 

Treatment. — In  the  early  stage  these  growths  are  easy  to  re- 
move. The  crust  can  be  removed  by  an  ointment  of  salicylic  acid, 
and  carbon  dioxide  snow  applied  to  the  base  for  thirty  seconds  with 
firm  pressure.  Another  way  is  to  curette  off  the  scale  and  then  use 
silver  nitrate.  When  a  heavy  crust  has  once  formed,  treatment  must 
be  more  radical,  and  the  growth  should  either  be  excised  or  treated 
with  the  actual  or  electric  cautery.  If  there  is  any  suspicion  of 
malignancy,  operation  must  be  extensive. 

SIMPLE  KERATOSIS. 

Clinical  Course. — Solitary  patches  of  keratosis  may  develop  in 
the  elderly,  usually  upon  the  face  or  the  hands  (Fig.  4).  They 
start  as  papules  from  1  to  3  mm.  in  diameter,  and  are  of 
great  surface  hardness,  due  to  a  piling  up  of  the  horny  layer.  This 
thickening  of  the  keratin  soon  becomes  black  in  color.  The  crust 
is  very  adherent,  and  usually  becomes  detached  only  once  or  twice 
a  year.  They  rarely  grow^  to  more  than  5  mm.  in  diameter,  and  are 
sometimes  multiple,  although  it  is  rare  to  find  more  than  three  or 
four  such  lesions  in  any  one  person. 

Histology. — Histologically,  the  changes  are  very  similar  to  those 
described  as  occurring  in  senile  warts,  but  there  are  no  signs  of  an 
undue  amount  of  fat  being  j)resent. 


40 


SKIX    CANCER, 


Malignant  Degeneration. — These  patches  may  become  maliirnaiit, 
tlu'  lirst  fhaiiiic  imtod  liciiiLT  ulcoratioii  and  sornns  tlischarjre. 


Fig.   4. — This  patient,   a  very  old  man,   has  had   this  horny  growth   upon   his   liand 
for  about  a  year.     It  was  cured  by  excision.     (Author's  collection.) 


Treatment, — Ti'eatineiil    is    identical   Avith   that   described   under 
senile  wavts. 


ARSENICAL  KERATOSES. 


That  arsenic  may  cau.se  kci'atoscs  is  not  a  particularly  unfamiliar 
fact,  but  it  has  been  Avithiu  the  past  fcAv  years  that  it  has  become 
generally  recognized  that  the  internal  administration  of  that  drug 
can  cause  keratoses  that  may  eventuate  in  carcinomata.  These  le- 
sions have  been  carefully  studied  by  Ilartzell,^-  Schamberg.^'^  and 
Fordyce,^*  all  of  -svhom  agree  on  the  essential  points.  Arsenic  must 
be  administered  over  a  considerable  length  of  time,  and  in  fairly 
large  amounts.  Typical  keratoses  appear  which  have  a  histology 
that  is  essentially  the  same  as  those  already'  described.  The  cancers 
are  prickle-celled  ones. 


"Hartzell:  Amer.   Jour.   Med.    Scien..    1897,    cxviii,   205. 
"  Schamberg:  Jour.   Cutan.  Dis.,  1907,  xxv,  26. 
"Fordyce:  Amer.  Jour.   Med.  Scien.,  1910.  Iv,   1G24. 


PIIKCANCKROUS   Di;i{ MATOSKS. 


41 


KERATOSIS  FOLLICULARIS. 

Wcndc^'''  has  rcyx)!-!*'*!  ;i  r(iii;irk;il)lc  cjisc  wlicrf  \\\('.  knratotic  le- 
sions of  Dai'icr's  discjisc  hccoinc  cjirciiionKiloiis.  It  is  only  surpris- 
ing that  this  condition   li;is  ikiI    occinrcd   more   U<i(\U(ini]y. 

CUTANEOUS  HORN. 

It  is  generally  known  1li;i1  culnncoiis  horns  often  bceoiiie  malig- 
nant, the  change  taking  place  ;i1  the  l)ase,  and  being  evidenced  by 
ulceration,   secretion,   jind    iiidiu'iil  ion    fJ^'ig.  5). 


Fig.  5. — A  cutaneous  horn  first  arose  upon  some  senile  warts.  "When  the  picture 
was  talcen,  there  was  infiltration  and  ulceration  at  the  base  of  the  growth. 
Microscopical  examination  showed  the  presence  of  early  cancer.  (Heidings- 
feld's  collection.) 

CANCER  OF  PARAFFIN  WORKERS. 

Schamberg^^  has  recently  j^ublished  a  most  complete  paper  on  the 
prevalence  of  cancer  in  tar  workers,  paraffin  workers,  and  chimney 

i^Wende:  Jour.   Cutan.  Dis.,   190S.  xxvi,   531. 
^'Schamberg:  Jour.   Cutan.   Dis.,   1910,  xxviii.    644. 


42  SKIN    CANCER. 

sweeps.  The  eriule  ]>eti'()leum  has  a  ])articiilarly  irritatiiifj:  effeet 
upon  the  skin,  especially  ai-ound  the  hair  fdllicles.  These  are  found 
to  be  filU'd  with  dark,  spiii\-  i)lu>is.  Not  iiifrecnu'iitly  keratoses  form, 
and  later  cancerous  chan<j:es  occur.  In  chimney  sweei)s  the  scrotum 
is  usually  afl'ected,  due  to  the  collection  of  soot  in  the  rujija'  of  the 
skin.  This  frequcntl\"  ri-sults  in  death  from  lymphatic  involvement. 
Cancer  has  also  been  recorded  as  occuiiiiiii:  in  tiardcners  who  use 
soot  in  the  eourse  of  their  work. 

XERODERMA   PIGMENTOSUM. 

I'liiia's  (K'script ion  of  the  clinical  course  of  tiiis  disease  still  re- 
mains classical,  and  but  little  has  been  ad<led.  He  states  that  this 
disease  was  lii'st   i"eco<>:ni/ed  by  IJiidei-  and   liy   Kaj^osi. 

Clinical  Course. —  It  usually  beuins  with  an  inllamniatoi-y  liyi)er- 
emia  and  a  freckle-like  condition,  the  freckles  doubtless  being  pro- 
tective in  intent.  As  a  «jeneral  i-ule.  oidy  the  exjiosed  parts  of  the 
skin  ai'c  invoh'ed  at  fii'st,  but  later  in  the  course  of  the  disease  the 
whole  skin  may  be  invoKi'd.  The  fii-st  chanjj^es  are  noticed  between 
the  ages  of  five  and  ten  months,  and  jjrogress  but  slowly.  At  a  lit- 
tle later  date  it  is  noted  that  there  are  atrophic  ai-eas  in  the  skin, 
and  also  venous  telangiectases  (Fig.  6).  Between  the  ajres  of  fifteen 
and  twenty  years  kei'atoses  usually  manifest  themselves,  and  from 
the  eai'liest  stages  the  skin  is  remarkably  rough  and  dry.  The  eyes 
are  exceedingly  sensitive  to  li^ht.  and  thi'  patient  liangs  his  head 
and  keeps  the  eyes  closed  when  the  illumination  is  at  all  bright. 
At  about  the  age  of  twenty  some  of  the  keratotic  patches  become 
malignant,  and  the  growth  of  these  carcinomata  is  usually  sIoav  and 
typical  of  rodent  ulcers.  Occasionally  the  cour.se  of  the  disease  is 
much  more  rapid;  in  the  patient  illustrated  in  Fig.  7  large  cancers 
had  developed  at  the  age  of  fourteen. 

Pathology. — Histologically,  the  lesions' have  been  studied  by  Un- 
na.  KaiJosi,''  Fordyce,^*  and  others.  The  very  earliest  lesions  have 
not  as  yet  been  sufficiently  studied.  l)Ut  the  second  stage — that  is, 
where  there  is  a  marked  increase  in  the  amount  of  pigment — is  well 
known.  The  basal  layer  of  the  rete  contains  an  abnormal  amount 
of  pigment,  and  the  rete  as  a  Mhole  is  thinned  and  atrophic.  The 
papilla?  are  widened  by  congestion.  The  changes  in  the  corium  are 
found  over  the  entire  skin.  The  varices  do  not  form  under  the  pig- 
ment, but  only  where  this  is  lacking.     I'luia  states  that  in  the  areas 


'"Kaposi:  Twentieth   Century   Practice   of  Medicine,   v. 
"Fordyce:  Jour.    Amer.    Med.    As.sn.,    1010,    Iv,    1624. 


J'RI'XJANCI'MtOIJS    l)i;H.\lA'r()SKS. 


43 


■of  excessive  pif^mcntation  tlic  pi^mciil  is  roiiml  iiol  only  in  the  rete, 
but  also  in  the  papilhiry  spjiccs,  pjtrtly  in  llic  lymph  spar-eH  and 
partly  in  the  hyper'li'()|)hi('  H[)iii(ll<'  fclls.  Scjillcrf-d  flnrnfts  arc  alHO 
found    in    1ii<^   iii)|icr   |»ri('kl(^   hiycr. 


Fig.  6. — This  boy,  aged  12,  had  .suffered  from  freckles  since  he  was  2  years  old. 
Atrophic  areas,  areas  of  pigmentation,  and  a  keratotic  lesion  upon  h's  neck  can 
be  seen.  Tlie  condition  is  one  of  xeroderma  p'gmentosum.  (Case  in  the  Johns 
Hopkins  Hospital.) 


44 


SKIX    CANCER. 


In  the  third  stage  there  exists  i,'reat  thickcniiifj:  of  the  horny  layer, 
so  as  to  form  liorny  ^varts  or  keratoses,  beneath  Avhieh  the  rcte  is 
deformed  in  spaces  corresponding:  to  the  black  areas.  In  the  lower 
]iricklc  layer  the  prickles  are  lost,  and  the  cells  consequently  arc 
misshapen,  and  there  is  considerable  intracolhilar  edema.  In  the 
retc  are  masses  of  closely  packed  epithelial  cells  loaded  with  pig- 
ment. At  times  collections  of  nevoid  cells  are  fouml  in  the  upper 
portion  of  the  corium,  all  loaded  with  pigment.  The  white  sclerotic 
spots  arc  due  to  an  obliteration  of  the  capillaries,  caused  by  the 
sclerosis  and  hypertrophy  of  the  connective  tissue  of  the  corium. 
There  is  usually  some  round-celled  infiltration  around  the  basal 
layer.  The  cancers  developing  in  these  patches  are  typical  basal- 
celled  carciuoiiiata.  showing,  however,  an  increase  in  pigment. 


Fig.  7. — The  same  patient  illustrated  in  Fig.  6.  Had  a  mnnbpr  of  will-ilcvelojied 
cancers  arising  from  the  Iteratoses.  Microscopically,  thoy  were  shown  to  be 
basal-celled.  The  condition  is  xeroderma  pigmentosum.  (Case  in  the  Johns 
Hopkins  Hospital.) 


The  condition  is  believed  to  be  due  to  a  congenital  lack  of  resist- 
ance to  the  rays  of  the  sun,  and  the  increased  pigmentation,  as  avcII 
as  the  early  erythema,  is  an  attempt  on  the  part  of  the  body  to 
protect  itself  against  the  actinic  rays.  It  is  not  unusual  to  find  a 
number  of  r-hildrcn  in  the  same  family  similarly  affected  with  lliis 
disease. 

Treatment. — The  prognosis  is  always  bad,  the  patients  may  be 
relieved  for  a  short  time,  but  eventually  death  results  from  carcinoma- 
tosis of  the  skin,  occasionally  complicated  by  visceral  metastases. 


PRKCANCiiKOCS    l));i<M  ATOSI-S.  4.'» 

Ti-catmcnt  in  iiiisaiisfrU'toty,  niul  siiii|ily  fDti.sisIs  in  rlflayinj^  the; 
fatal  termination,  ^riic,  ]);iticii1.s  should  l>o  cxposf^l  to  Hunlif^ht  as 
little  as  possible,  jiikI  it  would  he  Ixillcr  il"  Ihe  windows  of  the  room 
in  whi(;h  they  are  k(!j)t  were  of  red  j^lass,  so  as  to  filter  out  th(! 
actinje  rays.  In  addition  to  tiiis,  the  e,\r)Osed  portions  of  the  body 
sliould  either  be  covered  by  a,  mask  or  by  a  7"ed  ointment  or  lotion, 
ealaniine  beinj^  faii'ly  s;i,tisfiu*toi'.\'  lor  1liis  purpose.  Whenever  a 
carcinoma  a})peai-s,  it  slionld  l)e  rjidif-ally  rcinovcd  at  onee,  or,  bet- 
ter yet,  the  keratoses  should  be  excised  as  sor)n  as  they  appear.  In 
other  respects  the  treatment  is  purely  symptomatic,  treating  symp- 
toms as  they  develop. 

SAILOR'S  SKIN. 

This  condition  was  originally  described  by  Unna  as  occurring  in 
sailors  who  were  much  exposed  to  weather  and  sun.  The  condi- 
tion, as  will  be  shown  later,  is  not  confined  to  seafaring  men,  but 
also  occurs  in  farmers  and  those  who  are  exposed  to  a  dry  climate 
and  excessive  actinic  rays.  In  both  of  these  groups  of  cases  there 
is  an  acquired  hypersusceptibility  to  actinic  rays,  as  opposed  to  the 
congenital  intolerance  that  appears  to  be  the  basis  of  xeroderma  pig- 
mentosum. 

There  first  appears  upon  the  exposed  parts  a  diffuse  cyanotic  red- 
ness. Pigment  spots  soon  appear,  but  the  areas  between  these 
''freckles"  may  or  may  not  lose  their  pigment.  Telangiectases  ap- 
pear, and  the  skin  becomes  dry  and  hard,  and  keratoses  usually  re- 
sult. This  condition  may  last  for  years,  but  usually  there  develop 
basal-celled  carcinomata,  that  run  the  clinical  coiu*se  of  rodent  ul- 
cers. 

When  this  condition  begins  to  develop,  the  patient  should  give  uj) 
an  out-of-door  life,  or  at  least  protect  himself  from  light.  In  the 
later  stages  the  treatment  consists  of  the  surgical  removal  of  the 
growths. 

FARMER'S   CANCER. 

The  condition  described  by  Unna  as  peculiar  to  seamen  is  also 
found  in  those  who  are  much  exposed  to  the  sunlight,  especially 
where  the  air  is  very  dry.  As  it  is  fairly  common  in  the  western 
part  of  the  United  States  among  those  following  agricultural  pur- 
suits, it  has  been  aptly  named  "farmer's  cancer."'  The  condition 
commences  with  a  deep  bronzing  of  the  skin,  later  the  cutaneous 
covering  becomes  dry  and  rough    and    minute    keratoses    develop. 


46  SKIN    CAXCKR. 

Hyde^^  has  thorouj?hly  consitlcrcil  this  type  of  dermatosis,  showing 
how  frequently  rodent  uleers  deveh)]^  upon  these  keratotie  patches. 
More  recently  Lawrence-"  has  called  particular  attention  to  the  ])rcv- 
alenee  of  this  disease  in  Australia.  Lawrence  states  that  out  of 
6,000  consecutive  cases  at  his  clinic  1.8  percent,  or  108  cases,  showed 
this  condition,  a  tigure  y:reatly  in  excess  of  the  pi'evalcnee  of  rodent 
uleers  at  the  European  skin  clinics.  He  attributes  the  condition  to 
the  {jrcat  nmouiit  of  sunshine  and  the  low  i-olativc  humidity  of  the 
atmosphere. 

The  treatment  is  the  same  as  for  "sailor's  skin." 

X-RAY  DERMATITIS.-' 

Clinical  Course. — This  sad  condition  was  much  more  fi'e(iuenl 
in  tlie  early  da\"s  of  x-ray  therapy  than  it  is  at  i)resent.  In  those 
days  the  oj^ei-ators  took  no  pi-eeautions  to  shield  either  themselves 
or  patients  from  long  continued  exposui'e  to  the  soft  rays,  and  the 
result  was  that  there  were  vei-y  many  sufferers.  The  condition  is 
in  every  way  analogous  to  the  conditions  just  described,  and  is  un- 
doubtedly caused  by  the  actinic  i-ays  of  the  Koentgon  tube.  The 
backs  of  the  hands  are  well  known  to  l)e  the  most  susceptible  i)or- 
tions  of  the  body,  and  here  it  is  that  this  condition  is  most  often 
seen. 

Again,  we  see  the  developing  of  an  excess  of  i)igment,  usually  in 
freckle-like  spots,  then  there  ai)i)ear  superficial  telangiectases;  the 
skin  becomes  dry  and  rough,  and  loses  its  secretions,  and  the  hairs 
fall  out.  The  nails  frequently  become  stunted  and  roughened.  Small 
horny  growths  appear,  usually  upon  the  site  of  the  freckles.  These 
later  develop  int«  either  ulcers  or  carcinomata.  The  cancers  may  be 
either  of  the  basal-celled  or  the  prickle-celled  type,  or  a  mixture  of 
the  two.  In  the  ease  of  the  squamous-celled  cancers  the  spread  is 
usually  rather  rapid,  and  local  removal  nearly  always  followed  by 
reeuri'ence,  and  at  times  by  metastases.  Even  the  basal-celled  car- 
cinomata usually  grow  fairly  fast. 

Pathology. — Pathologically  it  is  conceded  that  the  fii-st  changes 
manifest  themselves  in  the  corium  and  not  in  the  epithelium.  The 
sweat  and  sel>aceous  glands  become  atroi)hied.  the  blood  vessels  are 
dilated,  and  there  are  signs  of  an  inflammatory  ])i-occss,  with  round- 
celled  infiltration. 


"Hyde:  Amer.   Jour.   Med.   Sc,   1006,   cxxxi,   1. 

*»  Lawrence:  Trans.    7th    Internat.    Congress    Dermat.    and    Syphil.,    Rome.    1912, 
1219. 

"Porter  and  White:  Ann.  of  Surg.,  1907,  xlvi,  649. 


1'UI';(;an(;i;k()i:s  I)i;i<ma'1()si:s.  47 

Treatment.  In  «l(';iliii^'  witli  fhis  \cry  sccions  iii;il;i(l_y  ;iii  ounaa 
of  pi'cvoiition  is  vvorili  iii.iiiy  poiitidH  ol'  ciifc,  ;ini|  fort uiuitcly  this 
fact  is  now  I'ecof^nizcd  by  cyvry  x-vny  worker.  'I'lic  IuiihIh  of  the 
physiciaJi  should  iic\ci'  he  cxposccl  to  the  (iiijiniit  ions  of  the  tuhc 
Prevention,  is  now  thoi-ou^hly  «l('alt  with  in  ;ill  of  llu;  execlhMit  works 
now  existing  on  the  subject  of  the  pr;iclic;il  iis(!  of  this  therjjf>eutie 
remedy.  The  callosities  should  he  renio\-ed  either  by  the  use  of 
the  knife  or  by  the  cautery  and  eui-ette.  'I'o  tlu;  author  it  seems  il- 
logical to  use  either  the  I{oentg(!U  tube  or  radium,  for  he  cannot 
help  feeling  that  there  is  grave  danger  of  thereby  aggravating  the 
condition,  recalling  tlint  \hc  troubh;  is  caused  jjy  light.  Whenever 
an  ulcer  appears,  it  should  ix;  (excised  and  skin-grafted,  and  cancei-s 
should  be  excised  with  an  ample  margin.  ]f  they  are  of  the  spino- 
cell  type,  amputation  and  I'cmoval  of  the  neighborly  glands  should 
be  seriously  considered. 

PAGET  S  DISEASE. 

Paget 's  disease  is  often  considered  as  a  precancerous  condition, 
but,  as  there  is  still  dispute  as  to  whether  the  cutaneous  lesions  ma}* 
not  be  secondary  to  the  cancerous  changes  the  writer  has  felt  it  best 
to  deal  with  this  subject  in  a  special  chapter. 

MARJOLIN'S  ULCER. 

Cancer  frequently  develops  upon  the  scars  of  various  dermatoses. 
Most  prominent  of  these  is  the  scar  resulting  from  ordinary  burns 
of  the  third  degree.  Cancer  originating  in  such  lesions  is  commonly' 
called  Marjolin's  ulcer.  The  first  manifestation  is  almost  invariably 
a  superficial  ulcer,  with  a  considerable  amount  of  rather  foul  dis- 
charge. A  fungous  overgrowth  often  results,  with  great  indura- 
tion around  the  edges.  At  other  times  there  is  simply  a  deep  ulcer, 
accompanied  by  induration.  Cancers  of  this  type  are  usually  of 
the  spinous-celled  variety,  necessitating  wide  local  removal,  and  enu- 
cleation of  the  draining  lymphatic  glands.  In  severe  cases  situated 
upon  the  limbs  amputation  is  usually  necessary. 

LUPUS  VULGARIS. 

Lupus  vulgaris  of  many  years'  duration  is  not  infrequently  com- 
plicated by  cancer.  Sequeira--  has  recently  published  an  excellent 
article  on  the  prevalence  of  malignant  change  in  lupus,  and  has  re- 
ported a  number  of  very  interesting  cases.     He  concludes  that  the 


"Sequeira:  Brit.    Jour.    Dermat.,    1908,   xx,    40. 


48 


SKIN    CANCKR. 


cancorous  dojifciieration  devcloi)s  only  in  long  standing  eases,  and 
usually  in  persons  about  the  prime  of  life.  It  is  usually  stated 
that  about  2  pereent  of  all  cases  of  lui)us  become  cancerous.  Con- 
trary to  the  statement  of  most  observers,  Sequel ra  In'lieves  that  this 
change  is  more  common  in  men  than  in  Momen.  The  change  takes 
place  more  frequently  u])on  the  faci-  tlian  elsewhere  (Fig.  8).  It 
is  still  questionable  whether  x-ray  treatment  of  the  lupus  has  been 
responsible  for  the  malignant  change,  but  apparently  cancer  is  no 
more  common  in  the  cases  treated  by  the  x-ray  than  in  the  cases 


Fig.  8. — This  woman  had  suffered  from  lupus  vulgaris  for  years.  A  deep  spino- 
celled  cancer  has  developed  and  is  invading  her  orbit.  (Heidingsfeld's  col- 
lection.) 


treated  bj^  some  of  the  older  methods.  At  the  same  time  it  must  be 
remembered  that  it  is  only  within  a  comparatively  few  years  that 
the  ray  has  been  persistently'  used  in  lupus,  so  the  future  may  hold 
many  such  cases  in  store  for  us.  The  tumors  are  almost  invariably 
of  the  prickle-cell  type,  and  spread  rapidly  and  frequently  met- 
astasize. Radical  operation  is  indicated  in  all  cases.  Local  re- 
moval and  radiation  of  the  base  of  the  ulcer  is  not  sufficient ;  it  may 
cure  a  few  cases,  but  cannot  give  good  results  -when  tested  on  many 
patients. 


PKJCCANCIOUOCS   l)i;iCM,\'l(;SKS,  49 


LEG  ULCERS. 


Chronic  leg  ulcers  rarely  become  euiiccrouH.  T'olli  I'.loof]«^oo(P^'  and 
CJotthciP'^^  have  noted  this,  the  former  havinj^  seen  but  three  caHeH, 
and  the  latter  having  been  able  to  collect  Init  ten  cases  from  the 
literature.  Most  dermatologistH  and  surjifcons  express  surjirise  tliat 
such  a  change  docs  not  take  place  more  frequently,  but  to  the  author 
it  does  not  seem  surprising  when  one  considers  that  cancer  prefers 
to  originate  from  a  dry  sore  and  not  from  a  moist  one.  In  common 
with  most  carcinomata  of  the  extremities,  these  growths  are  usually 
of  the  spinous-cclled  type  and  hence  are  very  malignant.  Operation 
should  consist  of  wide  local  removal,  the  glands  likewise  being  taken 
out.  Amputation  is  frequently  necessary.  In  the  case  illustrated 
in  Fig.  30  the  growth  was  curetted  and  excised,  and  thoroughly 
cauterized  with  acid  nitrate  of  mercury,  and  has  escaped  recurrence 
for  three  years. 

LUPUS  ERYTHEMATOSUS. 

Lupus  eryfliematosus  scars  occasionally  become  the  seat  of  skin 
cancers.  Dubreuilh  and  Petgcs-''  have  collected  all  of  the  cases  re- 
ported in  addition  to  recording  two  of  their  own.  In  practically 
all  of  the  patients  the  lupus  had  existed  for  many  years,  and  the 
neoplasms  originated  upon  the  scar  tissue.  So  far  as  can  be  judged 
from  the  rapidity  of  their  growth,  they  were  of  the  spinous-celled 
variety.  More  recently  Janeway-*'  has  recorded  another  case  occur- 
ring after  the  use  of  carbon  dioxide  snow.  Gottheil,  in  discussing 
this  case,  held  that  previous  x-ray  treatment  was  probably  the  true 
factor. 

BLASTOMYCOSIS. 

That  the  lesions  of  hlastomycosis  may  become  cancerous  has  been 
shown  by  Bloodgood-'  in  a  case  that  the  writer  was  fortunate  enough 
to  see  with  him. 

SYPHILIS. 

Sypliilitic  ulcers  are  often  referred  to  as  undergoing  malignant 
degeneration,  but  the  condition  is  certainly-  unusual.  The  change 
may  take  place  either  in  an  ulcer  or  in  the  scar  produced  by  such 


='Bloodgood:  Progressive  Medicine,  Dec,   1904. 

=*  Gottheil:  Jour.  Amer.  Med.  Assn.,  1912,   Ivix,   14. 

=5  Dubreuilh  and  Petges:  Ann.  de  dermat.  et  de  syphil.,  1909,  x,  106. 

^''Janeway:  Jour.   Cutan.  Dis.,   1910,  xxviii,   140. 

-■  Bloodgood:  Progressive  Medicine,   Dec,   1907. 


50  SKIN    LANCLK. 

an  ulecr.  usually  the  latter.  In  the  former  instance  it  is  noted  that 
the  j^ranulation  tissue  beeoines  raised  at  some  ]H)int.  and  that  it 
bleeds  very  readily.  The  tissue  is  friable,  and  is  sli<;htly  pnlrr  tlian 
the  rest  of  the  granulations.  Induration  ni;i>-  he  fell  aituuid  llie 
edf^es.  The  further  course  siiows  eithei-  a  (lc(|ily  i'atin>r  ulcer  or  a 
funjjjous  growth,  or  a  combination  of  tlu'  two.  These  lesions  ari' 
usually  of  the  more  malignant  type.  ;iihl  hciicc  (Icniand  extensive 
operative  interference. 

INFLAMMATORY  DERMATOSES. 

Eczi))i(i,  licJiDt  i)hi)uis  <ni(l  })s(>ri(isis  ( ll;ii1/.cll.-"'  i-ih)odgood-")  oc- 
casionally give  rise  to  cancer  of  the  skin.  Iml  in  the  \iist  nia.)oi'it>' 
of  the  cases  repoi'ted  it  is  ])i'ol)al)le  thai  either  arsenic  or  x-i-iiy  was 
the  true  cause. 

SINUSES. 

Bloodgood  frequently  refers  to  .sintisis  a)t<l  fistulas  as  being  the 
starting  points  of  epithelial  neoplasms.  Init  admits  that,  when  one 
considers  the  frequency  of  such  conditions,  the  subscfiuent  develop- 
ment of  cancer  is  rare.  lie  also  mentions  one  case  of  malignant 
change  in  a  bedsore. 

WENS. 

Wens  may  serve  as  the  starting  points  of  cancer  according  to 
Bloodgood,^"  who  has  recorded  three  cases  where  malignant  change 
took  place  in  the  wall. 

NEVI. 

Vascular  or  pigmented  nevi  not  infi-e(|uently  become  tlic  stalling 
points  of  sarcomata,  and  rarely  of  carciiunnala  of  the  skin. 

PAPILLOMAS. 

The  fibro-cpithcliomata  of  tlic  sl-in,  commonly  called  ])apillomas, 
frequently  give  rise  to  either  basal-  or  i)rickle-celled  cancers,  espe- 
cially when  they  arc  subject  to  chronic  irritatio 

=»Hartzell:  Anier.   Jour.   Med.   Scien.,   1899. 

="  Bloodgood :  Progressive   Medicine,   Dec,   1907. 

'"Bloodgood:  Progressive  Medicine,  Dec,  1913. 


on. 


I'KI'MMNCICKOCS    DI'Mt.MA'I'O.SKK. 


CONCLUSIONS. 


Ill  ;i,  rccciil  review  ol'  llie  liler;it  iire  Siitloii''  itoiiils  oul  llwil  the 
lino  scf)!! rating'  iiiiili^ii;iiil  I'l-oin  l)eiii;jii  epit  helinl  ^m'owIIis  rjf  lh(!  skin 
is  often  ;i,  very  obscure  one,  ;iii(l  1li;i1  Iiiiiums  of  the  ro(|eii1  iileer  1\7>f; 
may  or'i{i;inu1,(;  in  the  lesions  of  Ihe  s<)-e;ille(|  miihii.h-  heni'rii  eyslie. 
epitheIioiii;i1;i.  He  does  not,  ho\ve\(^r,  jij^ree  wilh  lli-idinj^sreld,"-'-  who 
believes  that  all  f^i'owths  of  this  tx'pe  ;ire  prenudif^njiiil   in  eharaeter. 

Both  Moiitgoniciy'''  and  Sutloii''  h;i\-e  sliown  how  i're(|nently  can- 
cer of  the  lip  stai'ts  in  seboi'i'heie  patches,  and  I'dt  \-eai's  i1  has  Ijeen 
known  that  cancer  of  the  t(jnj;iie  fi-c(iuenll\'  originates  in  syphilitic 
lesions  as  well  as  in  leukoplakia. 

Bloodgood'''  states  that  every  ease  of  cancer  of  th(!  skin  of  whicli 
he  has  a  complete  record  originated  from,  some  abnormality  of  llie 
skin,  and  not  from  normal  epidermis.  He  also  states  that  out  of 
forty  cases  of  cutaneous  sarcoma,  thirty-tw'o  originated  from  dis- 
tinct skin  lesions,  usually  the  scars  of  burns.  These  statements  show 
that,  if  all  apparently  harmless  cutaneous  growths  were  removed, 
we  should  have  fewer  cancers.  It  also  means  that  Ave  should  do 
our  best  to  promptly  heal  all  lesions,  and  not  allow  them  to  drag 
along. 


"Sutton:  Amer.   Jour.    Med.    Scien.,    1913,    cxlv,    819. 
==  Heidingsfeld:  Jour.  Amer.  Med.  Assn.,   1912,  Ivix,  256. 
33  Montgomery:  Jour.   Cutan.    Dis.,    191.3,   xxx,    82. 
w  Sutton:  Jour.   Amer.   Med.   Assn.,   1913,   Ix,    1774. 
'SBloodgood:  Progressive  Medicine,  Dec,  1912. 


CHAPTER  IIT. 
EPITHELIAL  WARTS. 

There  are,  of  eoiirsc,  two  varieties  of  epitlielial  warts — the  be- 
nign and  the  malignant. 

BENIGN  WARTS. 

Both  clinically  and  i)athologically  the  benign  warts  may  be  di- 
vided into  four  main  classes,  each  of  which  contains  subdivisions. 

A.  Keratoma t a. 

a.  Simple  keratoma. 

b.  Clavus. 

c.  CjiUus. 

d.  Cutaneous  horn, 
c.  Angiokeratoma. 

B.  Acanthoma   (spino-celled  tumor). 

a.  Molluscum  contagiosum. 

C.  Mixed-celled  tumors  (rctcomata). 

a.  Verruca  vulgaris. 

b.  Verruca  digitata. 

c.  Verruca  filiformis. 

d.  Condyloma  acuminata. 

e.  Semi  globular  wart. 

f.  Pedunculated  fibroreteoma. 

g.  Seborrheic  warts. 

h.  Acanthosis  nigricans. 

D.  Basal-celled  warts. 

a.  Nevus-like  warts. 

b.  Multiple  benign  cystic  epithelioma. 

In  addition  to  tlie  true  Avnrt-like  growths,  certain  infectious  dis- 
eases of  the  skin  frequently  assume  a  papillomatous  overgrowth,  con- 
sisting of  hypertrophied  epithelium.  Among  these  may  be  men- 
tioned lupus  vulgaris,  and  various  other  forms  of  tuberculosis  of  the 
skin,  frambesiform  .s^-philis,  blastomj'cosis,  yaws,  and  occasionally  ec- 
zema. 

The  different   growths  mentioned   above  form   a  veritable  hodge- 

52 


KI'I'l'IIKMAfj    WAK'l'S.  .0.5 

podge,  a  set  of  tumors  yory  (lifTercnt  in  lli<ir  cliiiicjil  rrir'inif(!stution8 
as  well  as  in  their  etiology.  Tliey  are  licrc  grouped  together  sim- 
ply because  they  all  i'orj/i  a  more  or  less  wart-like  projeftion  above 
the  level  of  the  skin  and  all  show  cititliclial   proliforalion. 

Keratomata. — Of!  the  true  keralomala  tlicr(!  are  several  vai'ieties, 
all  sufficiently  well  described  in  the  text-books  on  dermatology.^ 

By  simple  keratoma  llic  antlidr  has  reference  to  the  single  or  mul- 
tiple keratosis  already  described  on  page  .30,  and  here  referred  to 
simply  for  the  sake  of  completeness. 

Clavus  or  cor^n  is  too  well  known  to  need  any  detailed  clinical  de- 
scription. Pathologically,  it  is  a  true  keratoma  of  wcdgc-like  shape, 
with  the  apex  pointing  downward. 

The  simple  callosity  is  likewise  too  well  known  to  merit  comment; 
it  is  a  diffuse  keratoma,  due  to  a  combination  of  pressure  and  fric- 
tion. 

The  cutaneous  horn  has  only  an  outward  resemblance  to  the  horns 
of  animals,  but  has  not  their  hardness,  being  about  equal  in  consist- 
ency to  the  normal  nail.  The  length  varies  from  5  mm.  to  10  or 
15  cm.  They  may  grow  singly  or  in  groups;  in  the  latter  case  there 
is  usually  one  large  one  surrounded  by  smaller  ones.  The  point  of 
origin  is  often  a  keratosis,  or  a  fibroma,  but  usually  a  seborrheic 
patch.  They  grow  out  from  and  are  attached  by  the  horny  laj'^er 
that  reaches  down  between  the  greatly  elongated  papillae. 

Angiokeratoma  Avere  first  described  by  Mibelli.-  They  appear  on 
the  hands  or  feet  of  young  persons  on  a  basis  of  local  asphyxia,  and 
consist  of  capillary  ectases,  with  a  surmounting  keratoma.  They 
first  appear  as  red  spots  that  disappear  under  pressure,  next  as  per- 
manent capillary  dilatation,  and  finally  the  keratoma  develops. 

Acanthoma  (Prickle-celled  Tumors). — The  molluscum  contagiosum 
is  the  only  true  tumor  consisting  almost  entirely  of  prickle  cells. 
Clinically,  they  are  sharply-defined,  single,  seniiglobular  tumors,  of 
a  translucent  appearance,  and  showing  a  central  depression.  They 
vary  in  size  from  2  to  6  mm.,  and  usually  appear  upon  the  faces 
of  children,  and  the  genitalia  of  adults.  They  are  undoubtedly  spread 
by  autoinoculation  and  contagion,  and  they  frequently  appear  in 
small  epidemics,  either  in  schools  or  among  the  patrons  of  the  so- 
called  Turkish  baths.  Upon  firm  pressure  a  colloid-like  material  may 
be  expressed  from  these  growths.     Histologically,  there  is  a  marked 


1  Crocker:  Diseases  of  the  Skin,   3d  ed.,  Phila.,  1905. 
Hyde:  Diseases  of  the  Skin,  8th  ed.,  Phila.,  1909. 
Pusey:  Principles  and  Practice  of  Derniatologj',  New  York,   1907 
Stelwagon:  Diseases  of  the  Skin,  6th  ed.,  Phila.,  1910. 

=  Mibelli:  Inter.  Atlas  Rare  Skin  Dis..  vii.   1SS9. 


54 


SKIX    CAXCKR. 


amount  of  ncaiithoid  tissue  that  has  uiulcr^'oiio  colhiid  dojifiMioratiou 
(Fiir.  fM. 

Mixed-celled  Tumors  (Reteomata).  Virnicit  vi(l<iiiri!<  is  ihc  com- 
inon  wart  so  often  found  upon  the  hands  and  scalji  o\'  the  }()un^. 
At  times  it  oeeui-s  upon  the  soles  of  tlie  feet,  then  causiufj:  a  very 
painful  aftliction.  That  the  conunon  wart  is  infectious  is  i)roYcn 
by  the  experiments  of  Jadassohn''  and  others,  ail  well  described  in 
Stelwat^on.  It  is  so  well  known  that  no  ileseription  is  necessary; 
suftice  it  to  say  that  the  so-called  seeds  air  simjily  i)ai'ticles  of  dirt 
that    have  ^'otten   down    between    the  e!on'j:ateil    int  rapapillary   spaces. 


Fig.  9. — Hi.stologically,  the  lesions  of  molluscum  contagiosum  consist  of  a  pure 
growth  of  spinous  cells,  which  have  undergone  degeneration.  (Author's  col- 
lection.) 


Histologically,  the  ])ai)illa'  arc  elonf^ated.  and  the  prickle,  basal  and 
horny  layers  all  hypertrophied. 

The  digitate  wart,  or  verruca  digitata,  is  simply  a  subvariety  of 
the  preceding,  the  projections  being  very  long,  and  are  most  com- 
monly found  upon  the  scalp. 

The  so-called  fdiform  ivarts  are  most  common  u]ion  the  neck,  of- 
ten appearing  in  great  numl)ers  at  the  same  time:  fifty  or  even  a 
hundred  may  develoi)  within   a   week.     The\"  usually  ai'ise  fi'om  the 


•Jadassohn:   Verhandl.    d.    Bten    Deutsch.    Dermat.    Ges.selsch.,    1895-06,    497. 


KI'I'l'lII'M-IAIi    WAiri'S.  .).) 

ncis'hborliood  ol'  llic,  liiiir  lolliclcs,  imd  ;iic  iinil'/iililciily  in  fcft  ifiiis. 
foi',  if  only  one  1)0  \o.\'i  bcliind,  iii;iiiy  inoic  will  iisiuilly  ajjfjcar. 
Tfistolo^-ically,  there  is  pi-olifci-il  ion  of  :ill  I  he  hivfrs  of  the  epi- 
thcliuin   arrai)fjf(Ml    around    ;in    incrcjiscd    nniount    of    (ihrons   lisKUc 

The  acnmindlc  condiilomuld,  of  vcvcrcdl  wai'ts,  occui-  afoun«]  tiie 
glaiis  penis  of  men  and  1h(!  lahi;i  of  women,  and  are  direetly  due  to 
irritating  discharges,  especially  of  ^^tnorrliea  or  dwincivjid,  mueh  more 
rarely  of  syphilis.  A  ty])ieal  growth  resembles  a  eoek's  eoml),  is 
bright  red  in  color,  and  has  numerous  sharp  projections.  Histo- 
logically, there  is  hypertrophy  of  the  prickle  and  b;is;d  biyers  r,f 
the  rete,  and  to  sojne  extent  of  the  fibrous  tissue. 

The  scmiglobuhir  vuirls  are  very  common  upon  the  faces  of  women, 
and  to  a  somewhat  less  extent  of  men,  and  occasionally  occur  else- 
where, rarely  upon  the  mucous  membranes.  Their  diameter  varies 
from  2  to  10  or  12  mm.,  and  they  are  very  firm  in  consistency.  Oc- 
casionally there  may  be  a  tuft  of  hair  at  the  top.  They  persist 
throughout  life,  with  very  little  tendency  towai-d  malignant  change, 
unless  subject  to  chronic  irritation.  Histologically,  there  is  pro- 
liferation not  only  of  the  fibrous  tissue,  but  also  of  the  prickle  and 
basal  cells. 

Another  common  variety  of  mixed-celled  wart  is  the  pedunculated 
one,  which  is  usually  found  upon  the  back,  and  varies  in  size  from 
5  mm.  to  5  cm.  in  diameter.  The  surface  is  thrown  into  many  lobu- 
lations. Histologically,  the  tumor  consists  largely  of  an  overgrowth 
of  fibrous  tissue,  but  there  is  also  an  excess  of  the  layers  constitut- 
ing the  rete.    These  tumors  only  rarely  become  malignant. 

The  sehorrJieic  ivarts  have  already  been  discussed  in  the  preced- 
ing chapter. 

AcantJiosis  nigricans  is  thorouglily  treated  in  Stel wagon's  book, 
and  a  complete  bibliography  is  given.  The  following  description  is 
from  his  article. 

The  cutaneous  lesions  consist  of  a  more  or  less  diffuse  pigmenta- 
tion, that  varies  in  color.  In  the  tiexures  most  especially,  but  to  a 
slightly  less  extent  over  the  rest  of  the  body,  the  skin  assumes  a 
papillomatous  overgrowth.  The  neck,  face,  lips,  and  mouth  are  also 
apt  to  share  in  this  hypertrophy.  Earely  these  may  degenerate  into 
cutaneous  cancers.  Couillaud  has  come  to  the  following  conclusions : 
"The  disease  is  a  syndrome  dependent  upon  abdominal  carcinosis 
and  characterized  (1)  from  a  clinical  viewpoint  by  (a)  a  papillary 
hypertrophy  and  a  cutaneous  pigmentation  having  an  essentially  re- 
gional character;  (b)  a  papillary  hypertrophy  of  the  mucous  mem- 
brane;   (c)    a  dystrophy  of  the  hair  and  nails;    [d)   absence  of  des- 


56  SKIN    CANCER. 

quamation;  (e)  existence  of  a  cachexia;  (2)  from  a  pathologic  stand- 
point by  a  carcinomatous  degeneration  of  the  abdominal  organs;  (3) 
histologically  by  lesions  of  hypertrophy  and  ])igmentation  in  the  rete 
and  corium." 

AVhencver  such  a  condition  is  present,  even  if  there  be  as  yet  no 
symptoms  of  abdominal  cancer,  an  abdominal  operation  should  be 
perfornxed,  for  there  may  be  some  hope  of  saving  life  by  so  doing. 

Basal-celled  Warts. — The  pure  basal-celled  warts  are  not  so  avcII 
known,  generally  being  confused  with  oitluu-  pigmented  moles  or  with 
the  pigmented  nevi.  They  have  been  sludu'd  by  Gilchrist*  and  Blood- 
good, °  who  have  shown  that  their  cells  arc  typical  basal  cells,  usually 
connected  at  some  point  with  the  basal  layer  of  the  rete.  They  do 
not  have  the  larger  size  of  the  nevoid  cells. 

The  multiple  benign  cystic  cpithcliomaia  probably  belong  in  this 
groujx     A  full  discussion  of  them  Avill  be  found  in  a  later  chapter. 

Treatment. — These  groAvths  can  be  effectually  treated  in  many 
different  ways;  the  pedunculated  ones  can  be  snipped  off  with  a  pair 
of  scissors,  and  the  base  cauterized  with  any  good  cauterizing  agent, 
preferably  the  actual  cautery. 

The  small  soft  growths  can  be  treated  w^ith  carbon  dioxide  snow, 
or,  better,  the  electric  needle,  by  any  one  of  the  chemical  caustics, 
or  by  excision.  In  any  of  the  growths  Avhcre  there  is  a  marked  ex- 
cess of  horny  tissue,  none  of  the  caustic  agents  should  be  used,  for 
only  disappointment  will  result.  The  growths  are  better  treated  by 
the  curette  first  and  a  caustic  second.  Even  without  local  anesthesia 
there  is  but  little  pain  to  curettage.  Of  course,  excision  can  always 
be  resorted  to,  but,  except  in  the  hands  of  the  expert  surgeon,  the 
scar  is  not  as  satisfactory  as  that  resulting  from  one  of  the  other 
methods.  With  an  expert  operator,  excision,  with  a  fine  linear  scar, 
is  the  method  of  choice.  Fulguration  is  painful,  useless  in  horny 
growths,  and  not  as  satisfactory  as  some  of  the  other  caustics.  The 
x-ray  should  not  be  used,  as  quicker  and  less  dangerous  methods  are 
always  at  hand. 

MALIGNANT  CUTANEOUS  WARTS. 

There  are  two  varieties  of  malignant  skin  warts — the  prickle-  and 
the  basal-celled.  There  is  still  a  question  as  to  whether  the  cancer- 
ous growths  are  malignant  from  the  start,  or  whether  they  repre- 
sent malignant  degenerations  of  the  benign  variety.     Borsf'  main- 


*  Gilchrist:  Jour.  Cut.   and  Gen.  Urin.  Dis.,  1899. 

»  Blood  good:  Progressive  Medicine,   Dec,   1904. 

•Borst:  Die  Lehre  v.  d.   Geschwiilsten,  Wiesbaden,  1902. 


IOITTiri;iJA[;    WAItTS.  .)/ 

tains  that  the  iypv,  is  (Icicfiniiuil  fiom  IIk;  very  earliest  gcnesiH  of 
the  tumor.  Of  eacli  cIjiss  there  ar<;  two  subvarieties — one  in  which 
the  surface  is  yjapilJomatous,  and  the  other  in  which  it  is  covered 
by  a  horny  crust.  Both  varieties  are  comparatively  rare,  and  are 
more  frequently  seen  by  the  surgeon  than  by  the  dermal oloj^ist;  the 
prickle-celJed  tumors  ai-e  more  frequently  encouiitei-ed  than  the  basal- 
celled  ncoplasnis. 

Prickle-celled.  Warts.^ — In  his  first  series  of  4f)8  epithelial  tumors, 
Bloodgood  saw  twenty-four  malignant  warts,  some  of  which  were 
distinct  papillary  epithelial  growths,  others  resembling  the  verruca 
senilis,  and  still  others  presenting  ulcerating  or  fungous  surfaces  at 
the  edge  of  the  growth.  The  most  common  situation  was  upon  the 
lips  or  the  face,  but  there  were  several  cases  upon  both  the  tongue 
and  the  penis.  In  only  one  instance  was  there  metastasis,  and  thai 
in  the  case  of  a  tumor  of  the  chest  wall.  This  is,  perhaps,  the  only 
class  of  spinous-celled  tumors  in  which  a  radical  operation  is  not 
demanded.  If  the  cases  are  seen  before  there  is  any  infiltration  at 
the  base,  wide  local  excision  will  suffice;  but  if  there  is  basal  in- 
filtration, the  neighboring  lymphatic  glands  should  be  removed.  At 
times  local  infection  will  give  basal  infiltration,  so  that,  if  there  be 
any  question,  the  surgeon  may  try  the  use  of  a  mild  antiseptic  oint- 
ment for  a  few  days,  and,  if  the  infiltration  disappears,  then  a  rad- 
ical operation  need  not  be  done.  In  this  class  of  tumors  removal 
with  the  knife  is  the  proper  treatment.  Pusey,  it  is  true,  has  had 
excellent  permanent  results  with  the  x-ray,  but  the  majority  of  oper- 
ators have  not  been  so  successful.  In  tumors  of  the  tongue,  Blood- 
good  considers  that  a  radical  operation  should  always  be  performed, 
and  the  same  is  probably  true  of  the  penis. 

Basal-celled  Warts. — Malignant  hasal-celled  warts  are  very  rare. 
Bloodgood  reports  one  occurring  upon  a  man  sixty-seven  years  old. 
The  wart,  which  first  resembled  a  "pimple,"  had  been  present  two 
years,  and  had  often  bled  because  of  ulceration.  Microscopically, 
the  growth  consisted  entirely  of  basal  cells  arranged  in  tubular-like 
growths.  There  was  no  recurrence  on  removal.  This  class  of  tumors 
can  be  treated  just  as  are  rodent  ulcers,  and  the  results  should  al- 
ways be  satisfactory. 

In  diagnosing  a  benign  from  a  malignant  wart,  the  first  thing  felt 
for  should  be  basal  induration;  secondly,  persistent  surface  ulcera- 
tion. The  diagnosis  should  usually  be  made  by  the  naked  eye  at 
the  time  of  operation,  the  surgeon  sectioning  the  tumor  and  look- 
ing for  the  fine  white  downgrowths  indicating  alveoli  f[lled  with  can- 
cer cells.     If  there  be  any  doubt,  either  a  frozen  section  should  be 


58  ^^KI^•    CANCER. 

stmlicd  before  further  operation  is  done,  or  seetions  can  be  hardened 
and  cut  in  the  usual  way.  and.  if  necessary,  operation  (•<>ini>leted  at 
a  later  date. 

In  obtaining;  material  for  seetions  it  is  best  to  employ  an  eleetrie 
eautery.  exeisiii^^  the  tis.sue  exactly  as  with  a  knife,  but  giving  a  wider 
margin,  inasnuich  as  the  heat  ruins  much  of  the  tissue  with  wliich 
it  comes  in  contact.  Frozen  sections  cannot  he  unreservedly  advo- 
cated, imismuch  as  it  is  very  difficult  to  i)r(»ducc  thin,  well  stained 
specimens,  and  hence  a  i)rop(i'  dia<iUosis  nmy  be  clouded  rather  than 
assisted. 

It  is  i>robable  that  the  ma.ioi'ity  of  malij>:nant  wai'ts  can  be  cured 
by  means  of  ju-oper  i-adiation.  althoui^h  at  the  ])i'esent  time  there  are 
absolutely  no  statistics  ujxju  wliich  to  base  this  opinion.  The  lack 
of  deep  intiltration  should  inalu'  these  tumors  ideal  subjects  for  pi'op- 
crly  administered  x-ra\s. 


chapter  iv. 
basal-cellp:d  carcinoma  1^ a  . 

The  (lifrerentiaUon  of  llu;  l)as;il-<'cllc(l  i^roup  of  lumoi-s  from  the 
other  epithelial  neoplasms  is  really  due  to  the  exeellent  work  of 
KrompechciV  aiul  in  America  the  attenlion  of  l)«)1li  dcrmatoloj^ists 
and  surgeons  has  l)een  especially  called  to  tlies(;  {^I'owths  l)y  the  ]>u\) 
lications  of  Bloodf^ood.- 

This  very  large  and  important  group  of  tumors  embi-aces  the  typi- 
cal Jacob's  ulcers  of  the  English  author  as  well  as  of  Unna,   the 


Fig.  10. — Diagram  of  the  sites  of  origin  of  220  cases  of  basal-celled  cancer.      (After 

Sequeira.) 


cancroid  of  the  early  writers,  and  the  rodent  ulcers  of  the  sur- 
geons and  dermatologists.  Owing  to  the  varying  clinical  and  patho- 
logical pictures  presented  by  these  tumors,  they  have  been  much 
confused  by  most  writers,  many  men  not  recognizing  that  the  histo- 
logical picture  might  vary,  not  only  in  different  stages  of  the  same 
growth,  but  also  in  sections  taken  from  different  parts  at  the  same 
time.     Some  English  authors  have  even  gone  so  far  as  to  speak  of 


^Krompecher:  Der  Basalzellenkrebs,   Jena,    1903. 
^Bloodgood:  Progressive   Medicine,   Dec.   1904. 

59 


60  SKIN    CANCKR. 

a  rodent  ulcer  becoming  mali«;nant,  wlien  in  reality  the  basal  cells 
were  simply  invading  the  tissue  in  a  slightly  different  way. 

Krompecher  has  shown  that  even  the  glandular  tumors  may  have 
a  different  picture  and  run  a  different  course,  according  to  which 
layer  of  the  glandular  epithelium  from  which  they  arise,  but  this 
need  not  now  concern  us,  thougli  it  does  seem  wise  to  point  out  the 
analogy. 

Occurrence. — These  tumors  are  usually  situated  upon  the  face, 
especially  upon  the  nose,  eyelids,  and  median  portions  of  the  check, 
but  may  occur  upon  any  other  part  of  the  face,  or  upon  the  back 
or  shoulders.  They  are  extremely  rare  upon  the  limbs.  Sequeira's^ 
composite  illustration  shows  very  clearly  where  they  usually  arise 


Fig.  11. — This  illusUalion  shows  biisal-celled  carcinomata  arising  from  different 
portions  of  the  rete.  Serial  sections  showed  that  there  was  no  connection  be- 
tween  the   various   growths.      (Gilchrist's   case.) 

(Fig.  10).  They  very  rarely  originate  in  people  under  thirty  years 
of  age,  and  are  most  common  in  the  decade  between  forty  and  fifty. 

It  is  usually  stated  that  males  are  much  more  frequently  affected 
than  are  women,  some  authors  even  stating  that  90  percent  of  the 
cases  occur  in  men  and  the  majority  believing  that  at  least  75  per- 
cent of  the  patients  are  of  the  male  sex.  Neither  Krompecher 's  nor 
the  author's  own  statistics  Avould  seem  to  bear  out  this  assumption, 
for  Krompecher  records  nine  in  men  and  eight  in  women,  and  the 
author's  figures  give  thirty-one  in  men  and  twenty-four  in  women. 

Pathology. — The  neoplasms  spring  from  the  basal  layer  of  the 


'  Sequeira:  Brit.    Jour.   Dermat.,    1913,  xxv,   172. 


BASAL-CKLLKD    CARCIXOMATA. 


61 


epithelium.  Not,  j)irrcf|iiciitlv'  1li(;y  ;i,rc  imiltifjlf;,  OHpocially  in  the 
typo  si)i'in}^in}^  from  .sobori'luMc  w;irts.  Petersen''  lias  deirionstrated 
that  tlie  growths  may  liave  a  iimltieeritrie  orif^iii.  In  a  reeerit  ease 
i'lom  the  Joliiis  ir()|)kiiis  l)('iMii;itolof?ieal  C'linie  it  foiild  be  dearly 
shown  that  in  one  nodule  tliei-e  wei-e  a  number  of  sejiaj-ate  and  dis- 
tinet  plaees  whei-e  mali^-iiant  i^roliferation  w;is  be-^'inninj^  (i'^if?-  Hj. 
The  whole  j^'rowth  was  seetioned,  and  lliesc  small  iiodulcs  had  no 
connection  with  each  other.  From  this  section  it  was  poHsible  to 
demonstrate  the  very  earliest  changes,  pliologi-aphs  of  which  arc  here 


Fig.  12. — The  earliest  lesion  of  cancer  is  a  downgrowth  of  the  epithelium.  Some 
of  the  prickle  cells  have  lost  their  nuclei.  There  is  very  little  infiltration  of 
the   surrounding-  corium.      (Gilchrist's   case.) 

reproduced.  The  first  change  noted  is  an  unduly  long  do-oiiward 
growth  of  the  intrapapillary  process  (Fig.  12).  There  is  some  de- 
generation of  the  rete,  and  many  of  the  prickle  cells  have  lost  their 
nuclei.  There  is  a  slight  invasion  of  the  rete  by  round  cells  and 
fixed  tissue  cells;  the  subpapillary  portion  of  the  corium  shows  a 
slight  increase  in  these  same  cells,  and  the  blood  vessels  are  dilated. 
The  second  stage  (Fig.  13)  shows  a  clubbing  of  this  downward 
growth;  the  basal  cells  have  begun  to  proliferate,  and  the  death  of 
the  cell  nuclei  is  very  apparent.  The  fibrous  tissue  of  the  corium 
shows  some  signs  of  compression,  and  there  is  an  increase  in  small 


<  Petersen:  Beitrage  z.   clin.   Chir.,  1902,   xxxii,   543. 


62 


SKIN    CAXL'KR, 


round  and  fixed  tissue  cells,  some  of  which  have  invaded  the  rete. 
In  the  third  staf?e  (Fiiu'.  14)   the  cancerous  lesion  is  distinctly  seini- 


r 


^ 


Fig.  13. — The  secoml  change  in  a  developing  basal-celled  cancer  is  a  clubbing  of 
the  downgrowth  shown  in  Fig.  12.  The  basal  cells  are  beginning  to  proliferate, 
and  dejienerative  changes  may  be  plainly  distinguished  in  the  spinous  cells. 
(Gilchrist's  case.) 


Fig.   14. — The  downgrowth  contracts,  so  that  a  solid  irass  of  basal  cells  is  formed. 

(Gilchrist's   case.) 


globular  in  shai)e.  due  entirely-  to  a  lu'oliferation  of  the  hasal  cells, 
there  niav  oi-  mav  not  be  infill  r;i1  ion  of  the  coriuni  l)y  inflainniatoi-y 


BASAri-(;i;i-iii;i)  (jAitcixo.viA'iA. 


(y.i 


cells,  and  ihc,  iU';i\\\  of  Ihc  nuclei  nC  I  lie  [iilc|:lc  fcllK  friii  ]>(■  floarly 
Hcen.  Sonic  nuclei  cati  he,  (list  iii^iiisli(<|  lyin<r  in  \;u'ij()]('H,  cither 
within  or  without  the  cells.  In  tlic  lonrlli  s\:)U"'  <\''\<j-  \^>)  the  buHal- 
ccllcd  f?rowtli  h;is  invfidcd  the  fctc,  so  tlint  siirl;ifc  ulfcration  has 
taken  X)l ace.  At  ;i  later  jx^ciod  the  l);is;il  iiicnihiJine  is  Inoken  tfirrtutrh, 
and  the  invasion   of  the  corium   Ix-^ins. 

After  the  invasion  begins,  Ihe  piit  holoj^iejil  [ticliire  vjiries.  Al 
first  there  ai'c  solid  nuisses  of  the  (lee[)ly-st;rniin<^  IkisjiI  eells  (F}^. 
16),  the  Carcinoma  haso<< Ihdare  soIuIkvi  of  Kromix'eher  ;in<l  I>lood- 
good.  The  solid  masses  do  nol,  li()\\c\ci',  lon^  rein;iin  so.  for  they 
either  degenerate  in  the  cenlci-,  forming  e\s1s,  or  else  ;in';intre  llicin- 


Pig.  15.^ — A  latei"  development  of  nodule  in  basal-celled  cancer  of  skin  shows  ulcera- 
tion  of  epithelium.      (Gilchrist's    case.) 


selves  in  solid  finger-like  downgrowtlis  (Fig.  17).  The  cystic  de- 
generations are  often  very  extensive,  and  it  is  not  nnusnal  to  find 
nnmerons  large  cavities,  surrounded  by  two  or  three  layers  of  can- 
cer cells.  This  stage  is  called  Carcinoma  hasocellularc  (.'^olidum  (t 
cysticam).  The  growth  may  have  a  distinctly  acinous  arrangement, 
there  being  many  fine  branches,  somewhat  like  the  limbs  of  a  tree. 
This  condition  forms  the  Carcinoma  hasocellularc  adenoides  of  Krom- 
pecher,  the  glandular  cpiflicliomata  of  the  older  Avriters.  and  the 
fuhular  cpiflicliomata  of  the  modern  dermatologists.  In  some  of  the 
large  fungating  neoplasms  there  may  occur  large  or  small  stellate 
alveoli  of  cancer  cells  imbedded  in  granulation  or  fibrous  tissue,  so 


64 


8K1X    CAXCKK. 


as  to  somewhat  i-osciublo  scirrhus  carcinoma  of  tlio  breast.  Ki'om- 
peehcr  has  no  designation  for  this  group,  l)ut  Hloodgood  calls  them 
Carcinoma  hasocdlulare  stcUatmn  (Fig.  18).  In  this  latter  group 
the  cells  may  be  so  flattened  out  ])y  ])ressure  as  to  be  almost  unrec- 
ognizable. l)ut  they  retain  their  affinity  for  the  basic  stains. 

Clinical  Course.— Clinically,  these  growths  start  upon  a  pre-ex- 
isting dermatitis.  Bloodgood  states  positively  that  in  every  case  of 
which  he  has  a  complete  history  there  was  an  antecedent  lesion,  how- 
ever small.     The  commonest  of  these  dermatoses  is  the  so-called  seb- 


Fig.  16. — Thi.s  section  was  from  a  typical  rolled-edge  rodent  ulcer  of  the  shoulders. 
The  basal  cells  are  arranged  in  solid  masses.  Notice  the  way  that  normal  epi- 
thelium and  some  connective  tissue  cover  the  mass  of  cancer  cells,  while  in 
other  portions  the  growth  may  be  seen  springing  from  the  surface  epithelium. 
This  invasive  growth,  without  change  in  the  overlying  skin,  is  common  In 
cancer  and   frequently   leads   to   incomplete   operations.      (Author's   collection.) 


orrheic  wart,  next  come  small  subepidermal  nodules,  then  keratoses 
of  various  kinds,  and  finally  scars  or  minute  ulcerations,  often  thought 
to  be  traumatic.  The  first  stage  of  the  cancer  that  is  noted  by  the 
patient  is  usually  a  slight  itching  or  burning  sensation,  and  at  that 
time  a  very  slight  increase  in  thickness  of  the  skin  can  be  felt.  Very 
shortly  after  a  minute  ulceration  takes  place  and  there  is  a  serous 
discharge   (Fig.  19).     Then  a  scab  foi-ms,  that  drops  off  from  time 


i5ASAri-CK[ii;i;i)  (;ak(;i\om.\')'a. 


65 


.,r^2'.^v 


v'.Vv 


■Vk^ 


Fig.  17. — This  section  also  demonstrates  the  manner  in  which  n  li:i..'ii- celled  can- 
cer may  be  covered  by  normal  epithelium.  This  case  had  been  treated  by  the 
x-ray  and  pronounced  cured.     Possibly  too  soft  a  tube  was  used. 


Fig.  18. — In  this  low-power  photomicrograph  of  a  basal-celled  carcinoma  it  can 
readily  be  seen  that  the  cells  are  lying  in  small  strands  and  also  singly  be- 
tween connective  tissue  fibers.  This  histological  picture  is  often  seen  in  the 
large  fungous  basal-celled  tumors,  and  at  times  makes  them  difficult  to  dis- 
tinguish   from    spino-celled   neoplasms.      (Author's    collection.) 


6G 


SKIX    CANCER. 


to  time,  ami  whenever  this  oeeurs  it  is  noted  that  the  ulcerated  area 
is  a  triile  lnr<;er.     "When  examined  closely,   a  few  minute,   greyish, 


Fig.  19. — This  man  is  suffering  from  two  very  early  basal-celled  cancers  of  his 
chin,  proven  by  histological  examination.  They  might  be  easily  mistaken  for 
benign  growths  at  this  stage,  but  slight  crusting  and  oozing  and  a  small  amount 
of  infiltration   lead  to  their  diagnosis.      (Sutton's   collection.) 

shiny  masses  can  be  seen  at  the  edge  of  the  open  sore,  and  this  edge 
is  usually  hard  and  slightly  elevated  (Fig.  20).     The  neoplasm  may 


BASAL-CKfJ>KI)    OAUCIN'OMATA. 


67 


then  take  any  one;  of  sc,v('r;il  coiii'scs,  ;ill  sliorlly  to  be  <U:^(w\\i(:<\. 
"When  one  of  those  growths  is  H(;ctioiied  and  c.xiuiuwcA  in  the  ^m'ohs, 
careful  inspection  will  revo;d  a  nuinher  of  w.vy  fitif;  wliitisli  lines 
radiating  downward  from  tlu;  tumor  proper;  these  nvc  the  alvfioli, 
filled  with  cancer  cells,  '^rhest;  white  lines  are  very  nnieh  finer  than 
those  occurring  in  tin;  |)riekle-eelled  eareiiiomata,  and  should  serve 
to  differentiate  between  the  two  kinds  ;it  tlie  time  of  operation. 
All  surgeons   should  become   faniiJijir   with    this   ehiss   of   tumors, 


Fig.   20. — This  young  farmer  is  suffering  from  multiple  basal-celled  cancers.     The 
oldest  is  of   seven  years'   duration.      (Sutton's   collection.) 


for  they  do  not  metastasize,  and  hence  it  is  not  necessary  to  remove 
the  adjoining  lymphatic  glands.  AVhen  glandular  involvement  is 
spoken  of  as  occurring  in  this  group  of  tumors,  it  is  probable  that 


G8 


SKIX    CANCER. 


there   is   an   error   in   dia«j:nosis,    and    that    the    irrowth    is    really   of 
ciihoidal-cellular  oriirin. 

CLASSIFICATION  OF  BASAL-CELLED   CARCINOMATA. 

According:,  to  the  later  clinical  c()urs(\  the  l)asal-celled  carcinomata 
may  l)e  divided  into  seven  ^i-onps — 1.  the  Ihit  rodent  ulcers;  2,  the 
nodulai-;  3,  the  roHed-eil^-e ;  4.  tiie  depressed  seardikc  cancer;  5,  the 
nioridieadike;  0,  the  l'unjratin<;:  7.  the  deep  uleeratinjj:.  All  of  these 
types  may  i-un  more  oi-  less  rapid  courses,  acciti'diiiLT  to  tlie  i-apidity 
of  neoplastic  iri-ow tli.  tlic   iiuti-itioii  of  Uw   part,  and  the  resistance 


Fig.  21. — This  old  lady  ha.s  a  Hal  ba.'^al-ci-llcd  carcinoma  of  the  ncse,  that  ha.s  re- 
curred after  being  curetted  and  cauterized  with  .silver  nitrate  one  year  ago. 
The  growth  originally  developed  from  a  semi-globular  wart  .similar  to  the  one 
on  the  upper  lip.     (Author's  collection.) 

of  the  invaded  tissue.  If  the  cancer  cells  multiply  more  rapidly 
than  they  are  able  to  invade,  a  funfjous  {growth  results.  At  times 
spontaneous  healinf?  may  take  place  in  the  center,  or  even  around 
the  edges,  but  the  Avhole  gro\vth  never  heals. 

I.     FLAT  RODENT  ULCERS. 

Clinical  Course. — The  flat  rodent  ulcers  usually  occur  upon  the 
face  (Fig.  21),  and  nuich  more  rarely  U])on  the  back.     It  is  the  most 


]5AHAri-('i':iJ.i:i)   (Jaiumnoma'I'A. 


69 


frequent  ty|)C  (niconnlcrcd  \>y  the  (|cnn;i1ol(i^'ist  ;iii(|  !.'rii(r;il  [irac- 
titioner.  It  l)Ofj''iiis  ;is  reddish  or  ]H'/dv\y-i^ycy  smooth  nodule.  2  1o  .'' 
mm.  in  diamctci-.  Siipcrlictiai  ulceration  takes  phiee  cnrly,  owiuu:,  to 
the  invasion  of  the  re1e  by  the  cancerous  tissue.  The  ider^ratcd  area 
is  covered  by  a  fairly  closely  adhereid,  hhiek  or  d;irkdjrown  crust, 
which  from  time  to  time  either  drops  off  or  is  pieked  off  hy  the 
patient.  When  this  occurs,  thei-e  is  sliMhl,  hleedinj/.  ;iiid  it  is  no- 
ticed that  the  ulceration  is  larger.  The  {growth  is  always  slow;  it 
may  take  one  year,  oi-  it  may  take  five  years,  for  a  diametr'c  of  1 


^ 

^ 

1 

1 

Rl 

i 

Fig.  22. — This  basal- celled  cancer  is  of  many  years'  duration.     Even  more  extensive 
ones   occasionally    come    under   observation.      (Heidingsfeld's    collection.) 

cm.  to  be  reached.  Slightly  enlarged  blood  vessels  may  be  noted  ex- 
tending into  the  surrounding  skin,  and  considerable  induration  is 
always  present.  On  inspection,  either  with  the  naked  eye  or,  if 
necessary,  with  a  hand  lens,  a  fevr  pearly  nodules  can  be  seen  just 
at  the  edge  of  the  ulceration.  The  skin  around  the  edge  looks  as 
though  under  great  tension,  is  shiny  and  thin.  The  tissue  beneath 
the  scab  resembles  ordinary  granulation  tissue,  but  is  less  hemor- 
rhagic and  more  friable. 

Pathology. — If  the  groAvth  be  removed  at  this  early  stage  and 


ro 


SKIN    CANCCR. 


examined  histologically,  it  is  at  once  soon  that  tlic  lu-w  tissue  con- 
sists entirely  of  basal  cells,  usually  arrani;od  in  solid  masses  (Car- 
cinoma hasocilhihnr  solid um).  At  times  it  will  lie  noted  that  these 
solid  alveoli  are  sending  out  fingerdike  dow  ngrowtlis  {Carcinoma 
hasociUularc  adcnoidcs) ,  or  that  distinct  cysts  liave  ])een  formed 
{Carcinoma  hasoccUuJarc  cjisticum). 

Later  Course. — U"  the  tumor  be  undisturbed  or  ineffectually 
treated,  one  of  several  things  may  happen.  In  the  first  place,  there 
may  be  "widespread  superficial  ulceration,  that  may  be  so  extensive 
as  to  cover  half  of  the  face  (Fig.  22).  In  some  of  these  cases  it  is 
remarkable  how  the  mucous  membranes  arc  spared.  Usually,  how- 
ever, the  orbit  is  invaded,  the  eye  destroyed,  and  death  takes  place 


Fig.    23. — This   basal-celled   (.-ancer   has   spontaneously    healed   in    the   center,   but    is 
spreading  along  the  periphery.     (Gilchrist's  case.) 


from  meningitis.  Second,  the  ulceration  may  take  place  as  just  de- 
scribed, but  there  may  be  some  f ungating  masses,  where  the  cancer 
cells  are  unable  to  rapidly  invade  the  underlying  tissue.  Third, 
there  may  be  considerable  spontaneous  healing,  with  the  formation 
of  a  considerable  central,  w^hite,  depressed  scar  (Fig.  23).  How- 
ever, on  at  least  one  of  the  edges  there  is  characteristic  ulceration, 
or  the  formation  of  cancer  nodules.  In  some  of  these  cases  the 
formation  of  scar  tissue  considerably  distorts  the  features,  pulling 
the  eyelid  downward,   or  the   mouth  upward   as  the  case  may  be. 


BASAri-(;i';iJ;i;[)  cakcinomata. 


71 


This,  of  course,  is  duo  to  llic;  foiil  racturcs  that  always  take  place  in 
scar  formation.  l^Vmrth,  th(!  i'ofiiiation  of  dc(!p  cavities,  due  to  severe 
ulceration  may  occur.  Secondary  infection  frefjuently  occurs,  some- 
times with  i)us  pi'oduciiif^  organisms,  atid  'sometimes  with  putrefac- 
tive bacteria.  The  edf^e,  even  from  a  coinfinrntively  early  stage  is 
slightly  elevated  and  always  veiy  hard,  nnd  ;it  times  cancer  plugs 
may  be  distinguished  in  it,  nltliougli  this  is  miicli  foniinoner  in  the 
priclde-celled  cancers.  The  iiidurution  is  due  not  oidy  to  the  can- 
cer cells,  but  also  to  the  innanimatory  cells,  and  to  fibrous  tissue 
that  is  frequently  formed.     The  surface  of  the  tumors  is  cr»rnpara- 


Fig.  24. — This  portrays  an  early  basal-celled  carcinoma  of  the  hand.     Cancers  upon 
the    hand   are  usually   spino-celled   and   metastasize.      (Sutton's    collection.) 


tively  smooth,  resembling  anemic  granulation  tissue,  and.  has  not 
the  rough,  warty  appearance,  so  characteristic  of  the  squamous- 
celled  tumors.  The  naked  eye  appearance  of  these  neoplasma.  upon 
section,  is  also  characteristic ;  infiltration  is  usually  comparatively 
shallow,  and  the  Avhite  lines  of  invading  epithelium  are  very  fine. 

Histologically,  in  the  large  growths,  the  early  solid  structure  of 
the  cancerous  alveoli  is  never  retained.  The  general  arrangement 
is  in  more  or  less  irregular  cylinders,  often  branching,  or  in  the  stel- 
late form  described  bv  Bloodgood.     There  is  often  much  fibrous  tis- 


72 


SKIX    CANCER. 


sue  at  the  edtros.  aiul  usuallx'  coiisidiTabU'  intlanmiatory  cxiulato.  oc- 
casionally so  severe  as  to  obscure  the  cancerous  ])icture. 

Diagnosis. — In  the  e.arly  stajj:es  tliese  growths  may  Ijc  confused 
with  tlie  iionmalignant  keratotic  conditions,  or  are  rarely  with  sim- 
ple inflammations.  After  ulceration  has  taken  place  only  syphilis, 
lupus  vulgaris,  or  more  infreciuently  lupus  crythematosis  or  even 
blastomycosis  might  simulate  cancer.  In  the  chapter  on  differential 
diagnosis  there  will  l)o  a  full  discussion  of  tlieso  diseases. 


^ 

BS|^.A=^^\"''  "^ 

i^H 

Fig.  25. — This  nodular  basal-celled  carcinoma  of  the  cheek  arose  from  a  sebor- 
rheic keratosis,  a  number  of  which  may  be  seen  upon  the  cheek.  (Heidings- 
feld's  collection.) 


II.     NODULAR  CANCERS. 

Clinical  Course. — The  nodular  cancers  arise  froiu  a  pre-existing 
lesion.  A  pearly  nodule  first  forms,  which  slowly  grows  until  in 
from  six  months'  to  one  year's  time  the  growth  has  attained  a  diam- 
eter of  1  em.  and  an  elevation  above  the  skin  of  about  the  same. 
The  lesion  is  roughly  semiglobular  in  shape,  may  be  .slightly  um- 
bilicated,  and  is  very  hard  and  firm  to  the  touch  (Figs.  24,  25). 
The  color  is  pinkish-white  or  grey,  and  there  are  dilated  vessels 
running  into  the  tumor.  Later,  ulceration  may  take  place  in  the 
center   (Figs.  20,  27),  and  the  neoplasm  run  any  of  the  courses  al- 


IIAHAL-('KIj^jKI)   carcixomata. 


(.'> 


ready  (icHcrihcd  iiihIci'  IIk^  iic;i(lih»,'  of  11k;  i\:\i.  rodent  uW-ff.  This 
type  is  in  reality  simply  a,  inodificatlnn  of  1li(;  loljcd  fd^/c  i-oddit 
ulcer  type. 

Pathology.— Ilistolof^-ically,  tln^  lesion  at  first  shows  the  char- 
acteristics of  the  Carcinoma  hasocdlidarc  soLiduw,  ])nt  later  chanf^cs 
to  some  of  other  types,  as  has  already  been  descriljcd,  the  only  dif- 
ference beinf?  that  the  changes  are  comparatively  slow,  and  11. at 
cysts  rarely  form. 


Fig.  26. — This  large  basal-celled  cancer  of  the  hand  sprang  from  a  seborrheic  kera- 
tosis. Notice  a  healed  lesion  upon  the  middle  finger.  This  is  an  unusual  tumor, 
for  neoplasms  of  the  hands  are  usually  of  the  spino-celled  type.  (Sutton's 
collection.) 

Diagnosis. — Gnmmata   and   benign    epithelial,    fibroid,    or    cystic 
tumors  must  not  be  mistaken  for  this  type  of  growth. 


III.     ROLLED-EDGE  RODENT  ULCERS. 

Clinical  Course. — The  rolled-edge  rodent  ulcer  is  very  closely  re- 
lated to  the  two  varieties  just  described,  but  more  closely  to  the 
second  type.  It  begins  in  the  identical  way  that  they  do,  but  is 
fairly  common  upon  the  back  and  shoulders  as  well  as  upon  the  face. 

The  tendency  is  for  these  tumors  to  grow  much  more  rapidly  than 


74 


SKIX    CANCKR. 


the  flat  type,  despite  the  fact  that  in  many  instances  there  is  no 
surface  ulceration  for  several  years  (Fig.  28).  By  the  end  of  a 
year  these  tumors  usually  have  a  diameter  of  several  centimeters. 
These  growths  have  a  distinctly  semiglobular  edge  and  a  correspond- 
ing depression  in  the  center,  so  that  they  resemble  the  crater  of  an 
extinct  volcano.  The  edge  is  extremely  hard,  and  the  skin  over  it  is 
tense,  tliin.  and  shinv,  and  there  arc  numerous  dilated  blood  vessels 


Fig.  27. — Tlii-s  large  ba-sal-celkd  cancer,  with  a  markedly  elevated  edge,  arose  from 
a  seborrheic  keratosis,  numbers  of  which  can  be  seen  upon  the  face.  (Heid- 
ingsfeld's  collection.) 


extending  out  into  the  normal  skin.  The  skin  of  the  central  por- 
tion may  or  may  not  show  signs  of  ulceration.  If  ulcerated,  there 
is  usually  but  a  slight  crust.  The  surface  of  the  exposed  or  cancer- 
ous tissue  resembles  granulation  tissue,  and  is  anemic  and  friable. 
The  late  course  of  these  neoplasms  is  the  same  as  that  of  the  two 
preceding  types,  and  the  pathology  is  identical  with  that  of  the 
nodular  lesions. 


IJASAIi-(Ji;M;i:i>    CAKCINOMA'I'A.  I'-) 

IV.     DEPRESSED   SCAR-LIKE   CANCER. 

Clinical  Course. — The  depressed  sear-like  cancers  are  compara- 
tively iirl"re(|U(!iit,  the  author's  series  containing  but  one  case.  As 
they  start  as  a  very  small  subepidermal  nodule  and  as  the  skin  over 
them  remains  intact,  they  frequently  remain  undiscovered  for  some 
little  time.  They  usually  arise  upon  the  cheeks  or  temples  of  those 
well  past  middle  life.  The  nodule  flattens  out,  and  slowly  spreads 
along  the  basal  layer  of  the  rete,  or  just  beneath  it,  and  as  a  result 
the  appearance  is  identical  with  that  of  a  depressed  scar,  except 
that  the  color  is  not  so  white,  and  that  the  normal  lines  of  the  skin 
are  to  some  extent  retained.  While  the  skin  is  thinner  than  usual, 
yet  to  examination  it  simply  looks  sunken  and  feels  bound  down, 
just  as  morphea  patches  do.     There  is  no  dilatation  of  the  surface 


Fig. 


28. — This  rolled-edge  rodent  ulcer  of  the  neck  has  no  ulceration, 
ered  v/ith  a  crust.     (Heidingsfeld's  collection.) 


but  is  cov- 


blood  vessels.  The  induration  can  be  plainly  distinguished,  feeling 
somewhat  like  a  small  coin  imbedded  beneath  the  skin. 

These  neoplasms  grow  very  slowly,  and  ulceration  does  not  take 
place  until  scA'cral  years  have  elapsed.  It  is  highly  probable  that 
tumors  of  this  type  may  end  in  the  morphea-like  cancer  shortly  to 
be  described. 

Pathology. — The  histopathology  is  the  same  as  in  the  preceding 
group. 


TO  SKLX    CANCER. 

Diagnosis. — Tl\e  ditTei-iMitial  iliatriiosis  nmst  lu>  iiiado  I'roiu  de- 
pressed scars,   and   I'l'om  iiu»ri)lioa. 

V.     MORPHEA-LIKE    CANCER. 

Clinical  Course. — Tlie  uKirplira-like  cancers  liave  reeently  heen 
described  in  detail  by  lleidinfjsreld.'  ^vll()  lias  collected  all  of  the 
reported  cases  in  addition  to  describini;  one  of  his  own.     According 


k 


U^' 


Fig.  29. — Thi.s  morphea-like  epithelioma  showed  upon  histological  examination  typi- 
cal basal-celled  structure.      (Heidingsfeld's  collection.) 

to  Ilcidingsfeld,  there  are  now  ])nt  eight  eases  of  this  variety  of 
cancer  on  record,  but  he  calls  attention  to  the  fact  that  many  cases 
of  so-called  ulcerating  morphea  should  undouljtedly  be  i)ut  in  this 
categoiy.     Cases  have  now  been  described  by  Danlos/'  Stelwagon,^ 


=  Heidingsfeld:  Jour.  Cutan.  Dis.,   1913,  xxxl,  370. 
•Danlos:  Ann.  de  dermat.  et  de  syphil.,  1809,  x,  656. 
^Stelwagon:  Trans.   Amer.   Deimat.   Assn.,    1899,    166. 


i{ASAri-(;Kiii>i:i)  cakcinomata.  ' ' 

ITartzcl],^  Fordycc,"  Pcnioi,^"  and  ir('i(liii<,'srcl<l.  imd  ;ill  of  iliosc  au- 
thors f(^(5l  that  11h^  cjiHcs  ;i,ro  not  csfx-fijilly  i'jiic  Imt  tli;it  thoy  arc 
frequently  overlooked,  'riicsc  lesions  nsu;dl\-  st;ir1  ;is  siii;ill  noijides, 
situjited  upon  the  temples  or  ni;d;ii-  eniinenees,  but  oee;isi<.n;dly  on 
the  l)ody.  They  are  sharply  defined  ;ind  spread  very  slowly,  it  of- 
ten taking  four  or  live  ye;irs  for  one  1o  rejieh  the  difuneler  of  2  ern. 
When  seen  ])y  the  derMKitoh)j^ists,  they  ai-e  sharply-th-fined  lesions, 
often  with  a  slightly  elevnted  i)eai'ly  border.  The  eentei-  is  white 
or  yellowish-white,  and  is  depressed.  The  violet  hue,  eharaetcristie 
of  sclerodenna,  is  laeking,  l)iit  there  are  dilated  blood  vessels  run- 
ning over  the  suj'faee.  The  edge  is  veiy  h;ird  to  the  toueh,  and 
the  center  feels  leathery  (Fig.  29).  There  ni;iy  or  may  not  be  small 
or  fairly  large  ideerated  ar-eas,  either  at  the  edge  or  nearer  the  een- 
ter  of  the  neoplasm.  Fernet  described  the  feel  of  the  tumor  as 
comparable  to  that  of  a  coin  imbedded  in  elnrmois  beneath  the  skin, 
but  other  authors  seem  to  think  that  it  is  not  so  hard  as  this.  The 
tumors  run  the  same  course  as  any  of  the  other  slow-growing  rodent 
ulcers. 

Pathology.— Histologically,  these  neoplasms   are  usually   of  the 
acinous  basal-celled  type,  undoubtedly  starting  as  solid  alveoli. 

Diagnosis. — Morphea,    or   possibly   syphilis    or    lupus    erythema- 
tosis,  might  be  confused  with  them. 

VI.  FUNGATING  TUMORS. 
Clinical  Course. — Fungous  tumors  are  either  large  or  small.  Oc- 
casionally a  basal-celled  neoplasm  may  be  fungating  from  the  be- 
ginning, but  this  is  rare,  and  this  characteristic  is  usually  of  late 
development.  Fungation  is  caused  by  the  cancer  cells  proliferating 
more  rapidly  than  they  can  invade,  so  that  the  growth  must  neces- 
sarily be  outward.  The  fungating  surface  may  be  covered  with  a 
slight  scab,  but  frequently  this  is  almost  entirely  lacking.  The  sur- 
face of  the  cancerous  tissue  is  comparatively  smooth,  having  but 
little  of  the  rough,  scraggly  surface  so  characteristic  of  the  prickle- 
celled  tumors;  in  fact,  it  is  even  smoother  than  in  cases  of  blasto- 
mycosis or  papillary  eczema.  .  Again,  the  tissue  resembles  anemic 
granulation  tissue,  although  slight  trauma  will  cause  free  bleeding. 
In  the  smaller  tumors  the  growth  is  very  slow,  and  there  is  com- 
paratively little  induration  beneath  the  surrounding  skin.  Some- 
times a  preexisting  ulcer,   either  cancerous  or  otherwise,  will  sud- 


sHartzell:  Jour.  Amer.  Med.  Assn.,  1909,  liii,  262. 
"Fordyce:  Jour.  Amer.  iMed.  Assn.,  1908,  li,  398. 
lopernet:  Ikonographia  Dermat.,    1912,   vi,   243. 


78  SKIN"    CANt-Fn. 

dcnly  begin  to  f ungate,  a  sure  sign  of  renewed  activity  and  rapid 
growth.  And  yet  even  in  these  cases  metastatic  growths  do  not  oc- 
cur. It  is  not  unusual  for  the  x-ray.  radium,  the  ineffective  use  of 
caustics,  or  even  of  tlie  curette  combined  with  caustics  to  set  up 
such  a  condition. 

Pathology. — Histologically,  tliese  fungating  tumors  sliow  eitiicr 
an  acinous  or  a  stelhite  arrangement  of  the  cancer  cells. 

Diagnosis. — This  class  of  neoplasms  must  be  told  from  the  rap- 
idly growing  fungating  type  of  squamous-celled  cancer,  as  well  as 
from  certain  of  the  infections,  as  granulomata  (granuloma  pyogeni- 
cum,  botryomycosis),  recently  so  ably  described  by  both  Sutton" 
and  Wile,^-  dermatitis  vegetans,  papillary  eczema,  blastomycosis,  and 
simple  exuberant  granulation  tissue. 

VII.     DEEP  ULCERS. 

Clinical  Course, — Deep  ulcers  are  rare,  and  in  tlie  majority  of 
them  it  is  probable  that  the  growth  consists  primarily  of  cuboidal 
rather  than  of  basal  cells.  They  usually  arise  upon  the  face,  gi'ow 
rapidly,  and,  owing  to  a  lack  of  resistance  of  the  tissues,  grow  down- 
ward rather  than  upward:  in  other  words,  the  fungoid  growth  is 
reversed.  At  the  start  they  may  have  acted  like  typical  rodent  ul- 
cers, but  because  of  injudicious  treatment,  which  injured  the  sur- 
rounding tissue,  they  may  have  found  it  much  easier  to  penetrate 
deeply.  The  cancerous  tissue  has  sloughed  out,  leaving  a  deep  hole. 
The  base  of  the  ulcer  is  usually  very  ragged  and  dirty,  there  is  fre- 
quently much  discharge,  often  of  a  foul  odor  due  to  putrefactive 
bacteria,  and  the  patient  may  be  toxic  from  absorption.  Death  takes 
place  from  hemorrhage  or  from  secondary  infection,  meningitis  some- 
times resulting. 

Pathology, — Histologically,  the  cancer  cells  are  usually  jirranged 
in  long  cylinders. 

DIAGNOSIS. 

In  diagnosing  basal-celled  tumors  from  prickle-celled  cancers,  sev- 
eral factors  must  always  be  borne  in  mind.  Fh'st,  basal-celled  tumors 
are  common  upon  the  face  and  fairly  common  upon  the  shoulders, 
but  are  very  rare  upon  the  limbs.  Second,  they  usually  originate 
from  keratoses,  and  frequently  from  cutaneous  abnormalities,  fre- 
quently considered  to  be  congenital.     Third,  their  growth  is  usually 


"Sutton:  Amer.  Jour.  Med.  Scien.,  1911,  cxlii,  69. 
""Wile:  Jour.  Cutan.  Dis.,  1910,  xxviii,  667. 


nAKAL-CKIilJ;!)    CAKCINOMA'IA.  7!J 

comparatively  slow.  FouKli,  lliflr  surf.'iff;  is  i-athor  smooth.  Fifth, 
the  iiidiii-ation  is  not  ;is  (l(;c|)  ;is  in  I  he  sf|ii;iiiious-c;ellofl  neoplasms. 
Sixth,  on  section  the;  infill i-ition  is  not  so  deep  and  the  fine  white 
lines  oi;  the  cancei'ons  alveoli  are  very  fine.  Seventh,  on  miei-oscopical 
examination  the  cells  are  very  different  from  the  prickle  cells,  for  they 
are  smaller  and  stain  more;  I'cadiiy  wilh  llie  basic  dyes,  such  as  hema- 
toxylin, while  the  pi'ickle  cells  stain  better  with  the  acid  dyes,  such  as 
eosin.  The  a]Tanf,^ement  of  cells  is  also  diffei'oit,  thei'c  beinf?  no  ten- 
dency for  the  basal  cells  to  form  whorls  or  pearls. 

TREATMENT. 

These  tumors,  even  in  nioderately  advanced  cases,  can  be  cured  by 
sufficiently  radical  operation,  for  they  do  not  metastasize  except  in 
very  exceptional  cases,  and  then  only  if  there  be  a  mixture  of  cuboidal 
cells.  As  regards  treatment,  there  are  several  schools.  The  surgeons 
advocate  the  knife,  and  certainly  show  a  very  high  percentage  of  per- 
manent recoveries  when  the  operation  has  been  thorough.  Certainly 
the  actual  cautery  is  even  better  than  the  knife,  and  it  would  seem 
to  the  author  that  when  the  knife  is  used  the  edges  should  always 
be  treated  with  some  caustic  agent  to  prevent  the  multiplication  of 
any  cancer  cells  that  might  have  been  deposited  upon  the  cut  surfaces. 
Some  believe  that  a  combination  of  the  curette  and  caustic  is  the 
best,  and  many  adhere  to  the  use  of  various  cancer  pastes  or  caustics. 
The  x-ray  has  many  advocates,  and  certainly  some  beautiful  results 
have  been  secured  with  it.  In  the  vast  majority  of  instances  the  der- 
matologists have  not  attempted  to  check  np  their  cases,  Pusey^^  and 
SherwelP^  forming  two  notable  exceptions  to  this  rule.  Hence  all 
cases  reported  as  cured  should  not  be  taken  too  literally;  the  cases 
must  be  followed  for  at  least  three  years  before  a  cure  can  be  pro- 
nounced. Bloodgood  emphatically  states  that  at  least  50  percent  of 
his  cases  that  were  cured  by  operation  had  been  subjected  to  various 
caustics. 

To  the  author's  mind  the  rules  of  treatment  are  simple.  If  the 
production  of  a  scar  makes  no  difference  the  actual  cautery  should 
be  used.  This  is  simpler  and  better  than  excision  followed  by  the 
use  of  a  caustic,  such  as  the  acid  nitrate  of  mercury,  for  the  operator 
is  not  troubled  by  hemorrhage.  If  the  growth  is  freely  accessible 
and  a  small  scar  is  allowable  the  knife  may  be  employed,  the  edges 
swabbed  with  alcohol  or  a  fairly  strong  antiseptic  that  will  not  pro- 
duce deep  necrosis,  and  the  wound  closed  so  as  to  produce  a  linear 


^'Pusey:  Jour.  Amer.  MeJ.  Assn.,  1913,  Ixi,  552. 
"  Sherwell:  Jour.  Cutan.  Dis.,  1910,  xxviii,   487. 


80  SKIN    CANCER. 

sear,  lii  small  «>:ro\vths  whcM-e  thoy  are  not  fi-cely  aeeossible,  as  in  the 
naso-faeial  fold,  ov  where  it  is  important  not  to  i)ro(luee  a  sear,  as 
upon  the  eyrlid,  the  x-i-ay  shouhl  l)e  tried.  It  is  imi)ortant  to  j;ive 
one  or  two  heavy  exposures  oi  a  measured  dose,  rather  than  to  try 
many  small  dcuses.  for  reeurrenee  follows  many  of  the  latter,  and  the 
ji;ro\vth  is  then  resistant  to  further  radiation.  In  aljsolutclx'  inoper- 
able )j:ro\vths  either  the  x-ray  or  radium  nuiy  be  emj)loyed.  However 
;i  small  do.se  of  I'adium  should  never  be  employed,  or  marked  stimu- 
lation of  the  neoplasm  may  occur.  In  the  ease  of  extensive  ji^rowth 
x-ray  is  the  be.st  method,  for  radium  seems  not  to  be  ai)i)lieable  ex- 
eept  in  small  tumors.  In  some  instances  a  combination  of  these  meas- 
ui-es  is  to  be  advocated.  For  instance  it  is  prol)abl\-  well  to  radiate 
after  every  operation.  In  all  instances  it  is  hipfhly  important  not 
to  employ  measures  that  are  insufficient,  for  such  treatment  is  almost 
sure  to  result  in  the  rapid  spread  of  the  cancerous  process.  Simple 
curetting,  cauterization  with  silver  nitrate,  earl)olic  acid  or  similar 
substances,  and  the  use  of  carbon  dioxide  snow  should  not  be  em- 
])loyed,  as  they  usually  do  much  more  harm  than  good. 


CilAPTEIi  V. 
CUBO-CELLED  CARCINOMATA. 

Origin.- — It  Avill  be  rciucnibcrcd  that  just  above  the  cells  fonn- 
iiig  the  basal  layer  of  the  rete  there  is  a  layer  of  cuboidal  cells,  cells 
somewhat  larger  than  the  basal  cells,  and  of  a  square  rather  than 
a  columnar  shape,  and  yet  with  no  prickles  and  not  staining  as  in- 
tensely with  the  acid  dyes  as  do  the  prickle  cells. 

Epithelial  tumors  may  arise  from  these  cells,  and  when  they  do 
they  possess  characteristics  of  both  the  basal-celled  and  squamous- 
celled  carcinomata,  or,  to  be  more  exact,  they  form  a  connecting 
link  between  these  two  radically  different  types.  They  have  many 
of  the  clinical  characteristics  of  the  former  in  that  they  grow  rather 
slowly,  and  frequently  run  a  course  identical  with  that  of  the  rodent 
ulcer,  and  yet  they  resemble  the  more  malignant  type  in  that  they 
have  a  marked  tendency  to  metastasize.  At  times  it  is  practically 
impossible  to  distinguish  them  histologically  from  the  basal-celled 
neoplasms,  and  Bloodgood^  thinks  that  there  are  undoubtedly  many 
mixed  cases. 

According  to  Bloodgood,  these  tumors  were  first  recognized  by 
Krompecher-  in  the  course  of  his  work  on  the  histology  of  the  basal- 
ccllcd  carcinomata. 

Clinical  Course. — Clinically,  these  growths  arise  from  pre-exist- 
ing lesions  of  the  skin,  just  as  do  the  other  varieties  of  cancer.  They 
may  form  either  fungous  or  ulcerative  lesions,  but  more  usually 
the  former.  The  tumors  often  grow  very  slowly;  in  a  case  reported 
by  Bloodgood  it  took  eight  years  for  a  diameter  of  12  cm.  to  be 
reached.  In  the  author's  case  (Fig.  30)  a  diameter  of  10  cm.  was 
reached  in  about  six  months ;  between  these  two  extremes  there  are 
all  stages  of  transition.  The  fungous  neoplasms  grow  much  more 
rapidly  than  the  ulcers,  and  metastasis  seems  to  take  place  sooner. 
The  cancerous  tissue  resembles  anemic  granulation  tissue,  that  bleeds 
easily  and  is  very  friable.  There  is  always  extreme  induration  about 
the  edges. 

Pathology. — The  gross  pathology  is  similar  to  that  of  the  squa- 
mous-celled  cancers,  for  the  alveoli  are  large,  much  larger  than  in 


'Bloodgood:  Progressive  Medicine,  Dec.   1004. 
=  Krompecher:  Der  Basalzellenkrebs. 

SI 


82  SKIN    CAXCKK. 

basal-celled  jirowths,  aiul  contain  fine  Mhite  M:i';nuilar  material  (can- 
cer cells)  that  can  readily  be  S(iueezed  out. 

AVhen  examined  under  the  microscoix'.  it  is  seen  tliat  at  first  the 
jrrowths  are  snlid.  ])ut  that  they  soon  l)e<:iii  to  spi-cad  out  in  Ion? 
finfrer-like  acini,  that  bi-andi  (Uit  more  or  li-ss  as  tiu'\-  Lrniw  down- 
ward. The  cells  resemble  larjje  sciuare  basal  cells,  ami  at  times  are 
»is  larfje  as  the  prickle  cells,  but  do  not  contain  i)rickl('s.  nor  do 
they  stain  with  eosin  as  well  as  the  si)inous  cells.  In  addition,  there 
is  no  tendency  for  the  formation  of  eilliei'  whorls  oi-  tlu>  moi-e  ad- 
vanced  e])ithelial  pearls. 

Incidence. — Out  of  a  total  of  DDT  cases  of  epillielial  tumoi-s.  of 
which   820   were   malignant,  Bloodgood^   reports  tliat   tliere   were   5 


Fig.  30. — This  cuboidal-celled  cancer  originattnl  in  a  varicose  ulcer  of  the  leg:, 
and  had  been  present  about  five  months.  It  has  remained  well  for  three  years 
since  local  removal  and  cauterization.  It  would  have  been  safer  to  have  re- 
moved  the  glands.      (Author's   collection.) 


percent  of  cuboidal-celled  tumors.  In  location,  tliese  neoplasms  are 
pretty  Avell  scattered.  In  a  study  of  sixteen  cases,  Bloodgood  states 
that  three  were  on  the  lower  lip,  five  on  the  face,  three  on  the  legs, 
and  one  each  on  the  scalp,  penis,  tonsil,  tongue,  and  neck. 

Diagnosis. — Tlie  diagnosis  must  be  made  from  Ixitli  ]n'ickle-  and 
basal-celled  cancers,  and  in  eases  of  a  mixed  type  of  tumor  this  may 
be  very  difficult.  The  naked  eye  diagnosis  depends  on  the  depth 
of  the  malignant  infiltration,  and  the  size  of  the  alveoli,  and  the 
microscopic  diagnosis  on  the  size  and  character  of  the  cells  and  the 
lack  of  whorls  or  pearls. 


'Bloodgood:  Amer.  Jour.  Med.  Sc,  1914,  cxlvii,  76. 


cubo-cj:lm;d  carcincj.ma'i'a.  83 

Treatment. — If  caught  yevy  c-u'ly,  siiii|)lc  cxcisioii  wiili  ;i  \\]<\(: 
niarg'iii  wiJl  usually  suffice  to  '/wt-  ;i  i)cnii;iiicnl  mrc,  hut,  if  tlic 
tumor  has  existed  for  ;iiiy  l(!ii}ftli  of  time,  i1  is  ;il)solutoly  impera- 
tive to  remove  the  ncif^hhoriiiji;  lyinpli  ^hiiiils.  i''iir1li(  r  study  of 
this  group  of  tumors  is  needed,  ms  vvc  ;irc  not  ,\(;t  cJeai-  as  to  when 
metastasis  takes  place,  although  ]i\U'  work  by  Bloodgood  seems  to 
show  that  this  is  often  ('oiiip;ii';i1i\'ciy  ciirly. 


CHAPTER  VT. 
SPINO-CELLED  CAKCIXOIMATA. 

Occurrence. — In  many  •ways  lliis  ni-oup  ol'  cancers  foi-nis  Ihc 
most  iiiipniiaut  one  from  a  clinical  standpoint,  for.  Avhcn  it  is  rc- 
meinberocl  tliat  the  lii)s,  tonjiuc.  and  ])ouis  arc  chiofly  affected  l)y 
this  type,  and  that  in  addition  a  larj^e  proportion  of  the  growths 
upon  tlic  cutaneous  surfaces  are  prielde  celled,  it  will  readily  be 
seen  tliat  the  more  important  of  the  surgical  e])ithclial  cancers  be- 
long to  this  category.  In  a  surgical  service  a])ont  two  of  these 
growths  are  seen  to  one  basal-celled  neoplasm,  ])iit  in  a  dermatologi- 
cal  service  the  reverse  is  the  case.  In  the  last  forty  cases  of  can- 
cer of  the  skin  seen  by  the  author,  nine  were  of  this  kind.  Ac- 
cording to  the  statistics  of  Bloodgood,^  these  tumors  are  most  fre- 
quently encountered  upon  the  lip;  secondly,  upon  the  skin;  thii-dly, 
upon  the  tongue ;  and,  fourthly,  upon  the  penis.  In  his  review-  of  GO 
cases  from  Bloodgood  *s  service  the  writer  found  that  the  neoplasm  up- 
on the  skin  arose  in  the  following  localities:  finger,  4  eases;  hand,  11 
cases ;  wrist,  2  cases ;  forearm,  2  cases ;  elbow,  2  cases ;  upper  arm, 
3  cases;  foot,  2  cases;  ankle,  3  cases;  lower  leg,  6  cases;  knee,  2 
cases;  thigh,  3  eases;  scalp,  3  cases;  face,  8  cases;  neck,  3  cases; 
trunk,  f)  cases;  and  scrotum,  1  case. 

Etiology. — For  all  practical  purposes,  the  stndy  of  tlie  i)recan- 
cerous  lesions  arc  the  most  important.  In  this  same  series  of  60 
cases  the  preexisting  maladies  were  as  follows:  scar  of  burn,  11 
cases;  scar  of  trauma,  5  cases;  sinus,  1  case;  senile  keratosis,  4 
cases;  "wart,"  14  cases;  "pimple,"  5  cases;  blastomycosis,  1  case; 
x-ray  dermatosis,  2  cases ;  lupus  vulgaris,  1  case ;  ulcer,  3  cases ; 
scratch,  1  case;  arsenic  keratosis,  2  cases;  uncertain,  10  cases.  Upon 
the  lips  almost  any  variety  of  lesions  may  serve  as  the  starting  point, 
while  upon  the  tongue  lesions  of  leukoplakia  or  of  syj)hilis  are 
especially  apt  to  become  malignant. 

Varieties. — Bloodgood  formerly  divided  the  s])ino('ellular  tumors 
into  epithelioma  spinocellulare  and  carcinoma  spinocellulare,  using 
the  latter  term  when  the  typical  arrangement  of  the  benign  proto- 
type was  lost.    From  a  clinical  standi)oint  there  are  but  two  types — 


'Bloodgood:  Progressive  Medicine,  Dec,   1D04. 
=  Hazen:  Jour.   Cutan.   Dis.,   1915,   xxxiii,   611. 

84 


SPINO-CKIJ.KI)    (JAIiCINOMATA. 


85 


the   Ofdiiiury   oik;   of   f';uK'cr   ;ui(]   llu!   oilier   of   IIh;    iii;ilitrii;iiit   wart 
that  ncithcf  inflliratcs  nor  inctastasizcH. 

Clinical  Course. — Clinically,  the  truo  cancors  fits!  appear  as 
nodules  that  usually  speedily  ulcerate.  They  may  then  be  either 
fungous  or  x>ure  ulcers,  or  a  combination  of  the  two.  The  surface 
is  usually  rough  and  irregular,  and  is  often  papillary.  The  color 
is  that  of  a  dirty  granulation  tissue,  with  some  whitish  splotches. 
Around  the  edges  there  may  be   some  cancer  plugs,   looking  some- 


Fig.  31. — Deep  prickle-celled  cancer  of  cheek  in  a  young  man.     (Sutton's  collection.) 


what  like  comedones,  from  which  masses  of  cancer  cells  can  be 
squeezed.  The  tissue  is  friable  and  bleeds  easily.  The  edge  is  usual- 
ly very  hard,  and  there  is  often  deep  induration.  Growth  is  usually 
comparatively  rapid,  and  it  is  not  unusual  to  see  extensive  involve- 
ment by  the  end  of  the  first  year.  A  tumor  of  nearly  15  cm.  di- 
ameter may  be  developed  by  the  end  of  two  months. 

The  most  important  thing  to  remember  about  this  group  of  can- 
cers is  that  they  frequently  metastasize.  The  author  made  a  special 
study  of  this  point  in  the  paper  already  referred  to,  and  has  found  that 
out  of  the  60  cases  reported,  38  were  followed  for  three  years  or 


86 


SKIN    CAXCKR. 


more,  ami  that  out  of  these  38  cases.  2'-^  liad  ilefmitc  metastases.  In 
certain  of  these  cases  the  metastatic  ^I'owths  ajiparently  formed  at 
a  very  early  date.  4  when  the  ])rimary  iri-owtli  uas  of  not  more 
than  one  montli's  duration.  Spinocelled  tumors  of  llic  l)ody  and 
heail  seem  to  l)e  rather  more  a])t  to  metastasize  tlian  tiiose  n]>on  the 
limbs,  and  those  oi'i^rinatin^  from  x-ray  or  arsenic  keratoses  seem 
especially   dan^^crous   in   this   respect. 

The  spinocelk'd  mali^'iiaiit  warts  first  appear  as  wart-like  growths, 
which  develop  rather  slowly.  I'licre  is  often  a  tendency  toward  ])e- 
iluiiculation.  and  llu're  is  no  cancci'ous  infiltrate  at  the  base.  As  a 
result,  these  ^'rowths  do  not    form   metastases. 


.Jtttp^ 

l^SK> 

^^M^  ^ 

^Hfc^'        ?a|fe 

) 

^^*'  ■ ,.     '^fjk 

L 

^^^^^^T/^^^^l 

fc. 

,^^^^^^^^^^ 

w^- 

Fig.   32. — Rapidly  growing  cancer  devoloiiiiiK   lioin    within    the   eai 

collection.) 


(Heidingsfeld's 


Pathology. — -If  one  of  these  tumoi-s  l)e  excised  and  then  cut  into 
halves,  a  number  of  interesting?  things  may  be  seen  by  the  naked 
eye — things  that  go  a  long  way  toward  making  an  accurate  diag- 
nosis. There  is  usually  rather  wide  and  deep  invasion  of  the  eorium ; 
pei'haps  of  the  underlying  muscle.  Bloodgood  states:  "The  epi- 
thelial alveoli  are  distinctly  white  in  color,  finely  granular,  and  ar- 
ranged in  a  more  or  less  uniform  pa})illary  shape.  .  .  .  The 
fine,  branching  white  lines  are  composed  of  masses  of  spinal-celled 
epithelium  on  a  connective  tissue  basis."  These  lines  are  very  much 
coarser  than  the  lines  in  basal-celled  growths,  for  in  this  latter  con- 
dition the  alveoli  are  usuall\'  Cdniparalivcly  small. 


,SPTNO-(;i;i.Iii:i)    CAKf.'lXOMATA. 


87 


On  luHtolo^'icuI  examination  ;i  niiinlxr  of  <lifr('r(;n1,  Ivjjck  fan  read- 
ily be  made  out  (Fif^K.  34,  ;5r)j,  ;ill  liou^di  llicrc  is  not  as  wide  varia- 
tion as  in  the  histof);itliolot;y  of  the  Icisfd-fdled  neoplasms.  At  the 
start  the  j^rowlli  is  nsii;dl>-  soTkI  ;  llicrc  is  ;i  dippinj/  down  of  the 
rctc,  the  new  growth  consislin^'  niniost  cn1ircl\'  of  ftrifkle  eells,  but 
the  basal  membrane  of  cuboidal  cells  s1ill  i'cni;iirnn(;  intaet.  Many 
oi"  these  prickle  cells  li;i\c  lost  llicir  nuclei,  in  olliers  Mty[)icjil  kaiy- 
okincsis  is  K<>iiif?  on;  some;  oi'  \hv,  cells  lia\e  undergone  vjirious  types 
of  dcgenei-jition,  already  sufficiently  discussed  in  chapter  I,  and 
there  are  eonsiderable  spaces  belwcen  1he  cells.      In  ad(|ition  to  this, 


WSL 

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^SH^^K 

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L^^HU 

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M 

1  i 

^^HP 

Fv^fiB 

wi 

^ 

k 

^ 

,'Vf 

fl 

ffl^^n 

1 

1 

1 

1 

i 

Fig.   33. — Prickle-celled  cancer  originating  in  the  mastoid  following  mastoid  opera- 
tion.     (Heidingsfeld's   collection.) 


the  prickles  are  disappearing.  Other  descending  alveoli  appear,  not 
at  more  or  less  distant  places,  as  so  fi'eqnently  occnrs  in  the  basal- 
celled  growths,  bnt  as  branches  from  the  original  downgrowth.  The 
next  appearance  is  where  there  are  a  nnmber  of  solid  alveoli,  side 
by  side,  serial  sections  showing  them  to  be  connected  and  not  sep- 
arate and  distinct.  These  solid  alveoli  may  be  large  or  they  may 
be  very  small,  so  small  as  to  be  only  four  or  five  cells'  diameter  in 
thickness.  In  these  early  stages  there  is  no  tendency  for  whorl  for- 
mation or  the  formation  of  epithelial  pearls,  bnt  these  changes  may 
come  very  shortly,  and  are  iisnally  apparent  abont  the  time  that  the 
growth  begins  to  divide  into  numerous  small  alveoli.     These  small 


88 


SKIN  canci:r. 


alveoli  are,  of  course,  the  processes  or  buds  that  have  been  nipped 
off  from  the  orijrinal  parent  growths.  When  one  studies  a  com- 
paratively late  squanunis-t'ollod  cancer  of  the  skin,  he  will  see  that 
it  usually  conforms  to  one  of  four  different  arrangements:  First, 
where  a  more  or  less  pa])illary  structure  is  maintained,  all  of  the 
alveoli  bcinfi;  about  ccjual  in  size,  and  where  tlic  cuboidal  basal  cells 
are  still  found  surronndinir  tlie  prickle  cells.  In  tlic  center  of  these 
alveoli  the  cells  are  often  foinul  ilattencd  out  in  a  concentric  shape, 
forming  the  well-known  whorls,  and  distinct  pearl  formation  may 
take  place.     Second,  tlicrc  may  lie  very  numerous  small  alveoli,  each 


"^^ 


Fig.    34. — High-power    pliMi'uiiicniKrapli    uf    prickle-celled    cancer. 

lection.) 


(Author's  col- 


composed  of  but  a  few  cells,  and  separated  from  its  fellows  by  con- 
nective tissue.  In  this  form  there  arc  usually  no  basal  cells  discern- 
ible, and  there  is  a  great  tendency  for  whorl  or  the  more  advanced 
pearl  formation.  Third,  the  neoplasm  has  a  distinctly  tubular  for- 
mation, the  cells  being  arranged  in  long  lines  that  have  many 
branches,  which  are  rarely  bordered  by  basal  cells.  And,  lastly,  the 
cell  arrangement  may  be  more  or  less  that  of  a  scirrhous  carcinoma 
— that  is,  small  islands  of  cells  are  found,  surrounded  by  connec- 
tive tissue.  This  type  is  analogous  to  the  Carcinoma  hasocellulare 
stellatum  of  Bloodgood,  except  that  here  we  have  prickle  instead  of 
basal  cells. 


SPINO-CEIjLED   C  a  RC  I N  0  M  A  'J"  A . 


89 


The  cells  thcrn,selv(!H  deserve;  study.  They  are  lar^^e,  iriore  or  1c8H 
angular  in  outline,  a,nd  stain  intensely  with  the  Ji.ei<l  dyes,  due  to 
the  presence  of  keratin.  They  rc^taJn  none  of  theii-  [trickles,  these 
being  lost  early  in  the  coiusc!  of  the  lunv  i^rowih.  Especially  have 
they  undergone  some  oi;  the  types  of  hyaline  degeneration  already 
described.  Where  crowdcid  closely  together,  the  angvdar  shape  is 
lost  and  they  appear  as  elongated  spindle  cells.  Various  types  of 
atypical  division  can  often  be  recognized. 

There  is  usually  considerable  ijifhinunatory  exudate  in  the  invaded 
tissue,  an  exudate  that  is  greater  than  in  most  cases  of  basal-celled 
grow^ths.  This  infiltration  consists  of  small  round  cells,  of  fixed  tis- 
sue cells,  and  occasionally  of  mast  and  plasma  cells,  an  exudate  that 
is  comparable  to  that  appearing  in  any  chronic  inflammatory  dis- 


■^w  -'Vmkt^  * 


Fig.   35. — Epithelial  pearls  in  a  squamous-celled  cancer.      (Author's    collection.) 


ease;  only  rarely  are  there  any  great  number  of  polymorphonuclear 
leucocytes,  and  then  usually  only  when  secondary  infection  has  taken 
place. 

As  will  be  readily  seen,  the  wdiole  histological  picture  is  essen- 
tially different  from  that  found  in  the  basal-celled  gro^^i:hs;  the 
cancerous  alveoli  are  larger,  invasion  is  deeper,  there  are  epithelial 
whorls  or  pearls,  the  cells  are  much  larger,  and  stain  more  intensely 
with  eosin  or  orcein. 

Prognosis. — Prognosis  depends  on  the  stage  of  the  growth  and 
the  extent  of  the  operation;  even  in  fairly  late  cases  the  mortality 
should  not  be  high  if  an  extensive  and  thorough  operation  be  done. 
The  diagnosis  must  be  made  early  if  good  results  are  to  be  obtained : 


90  SKIN    CANCER. 

this  is  especially  trui'  iu  •rrowtlis  (iriirinatin<i:  upon  the  lips,  tongue, 
or  jtenis.  feu-  here  iin>'  di-hix'  usuallx"  ri'sults  in  extensive  jrlandular 
metastasis. 

Treatment. —  In  the  t)])ininii  of  the  wi-itei-  Xlw  t ri'alnient  slioiikl 
be  entirely  surgieal,  leavinir  x-ra\  <tr  radium  for  the  KO-ealled  in- 
operable cases.  It  is  ti-ue  that  I'usey"  aiul  others  have  obtained 
admirable  results  from  the  x  ray  iu  many  cases  of  this  type  of  neo- 
plasm, but  the  majority  of  otiier  workeivs  have  not  been  so  fortunate, 
j)resunuibly  because  they  eouhl  iu)t  use  their  ajjparatus  as  efhciently 
as  Pusey ;  hence  it  seems  a  lunn  o(  treatment  that  is  not  suited  for 
the  majority  of  cases.  Another  objection  is  that  it  is  difficult  to 
determine  when  nu^tastases  to  the  neighborinj'  jiflands  have  taken 
place,  and,  as  Pusey  himself  admits,  it  is  very  unsafe  to  treat  with 
the  rays  any  tumor  that  has  metastasized.  Certainly  no  prickle- 
celled  tumor  arising  from  the  mucous  surfaces  should  ever  be  treated 
with  the  rays,  unless  the  ])atient  absolutely  refuses  operation,  and, 
if  such  a  treatment  be  attempted,  the  patient  should  si^n  a  state- 
ment that  he  assumes  all  of  the  responsibility. 

A  com])lctc  excision  of  the  tumor,  of  the  underlying  fat  and  fascia, 
of  the  lynipliatic  vessels  and  glands,  all  l)eing  removed  in  one  piece, 
is  the  ideal  operation.  In  a  very  early  case,  Avhere  the  growth  has 
existed  but  a  week  or  two.  complete  local  excision  is  sufficient  if 
the  growth  be  upon  tlie  skin,  hut  not  if  it  be  U])on  mucous  mem- 
Ijrane.  In  snuiU  tunu)rs  a  nmrgin  of  at  least  half  an  inch  should 
be  given;  in  large  tumors  an  inch  or  more,  and  the  incision  should 
always  slope  awinj  from  the  tumor,  so  that  a  wide  area  of  fat  and 
underlying  structure  can  be  I'emovcd,  and  enough  .skin  left  for  ])lastic 
work.  In  all  of  the  late  cases  the  neighboring  glands  should  be  re- 
moved, and  it  Avcre  better  if  the  lymphatics  connecting  the  site  of 
the  prinuiry  growth  with  the  glands  could  be  taken  out  in  a  ])]ock 
operation. 

The  problem  in  ti'eating  spiiio-celled  cancel's  is  to  completely  re- 
move the  local  growth  and  also  the  draining  glands.  In  a  recent  case 
under  the  care  of  Dr.  H.  H.  Kerr  and  myself  this  problem  was  solved 
in  an  interesting  way.  The  primary  growth  was  situated  over  the 
junction  of  the  parotid  gland  and  Steno's  duct,  so  that  surgical  re- 
moval would  have  necessitated  dissecting  out  this  gland  and  prob- 
ably cutting  the  facial  nerve.  An  attempt  to  dissect  out  the  nerve 
in  a  cancerous  field  did  not  apiieal  as  being  good  surgery.  As  a  re- 
sult Kerr  did  a  block  o])ei-ation  upon  the  glands  of  the  neck,  while 
the  author  subjected  the  primary  lesion  to  deep  radiation.     The  im- 


'  Pusey:  Jour.  Amer.  Med.  Assn.,  1913,  l.\i,  552. 


SPINO-CELLKD    C.'AItCI  NO.VI  A'lA.  01 

jiicdijiic,  rcsiills  were,  cxccllciil .  Siidi  ;i  pi'D'-iil  u  ic  piohahly  has  a 
i-illicr  wide  field  ol"  usefuliicss. 

The  use  of  caustic  pastciH  is  inciilioncd  only  1o  In;  c()]\<\<-ri\ii<-<\  : 
they  do  not  I'each  sufficiciitly  deep  lo  d(;stroy  the  oullyinu  fdls  un- 
less a  {'■r-eat  (iiiautity  is  usee,!,  aud  then  l(;i\(;  a  wound  that  is  a 
thousand  times  woi-se  than  any  incision;  in  addition,  they  arc  very 
painful  while  beinj^'  aj) plied. 

Artichis  concerning  these  n(H)i)lasms  ha.vc  Ijcen  written  by  I>orst,'' 
l^lood!4'oo(V'  Franz,"  P>()i'rniann,'  Von  Brunn,**  Steincr,"  McGlannan,^" 
Volkmann,^'  and  iiiyself.^- 


■•Boi'st:  Die  Lehre  von  den   Geschwulsten,   Wiesbaden,   1902. 

"Bloodgood:  Progressive  Medicine,  Dec,  1907,  1908,  1912;  Jour.  Amer.  Med.  A.s.sn., 
1906,  xlvii,   1740;  Amer.   Jour.   Med.   Sc,   1914,   cxlvii,   76. 

"FrsLUz:  Beitrage   z.   klin.   Chir.,   1902,   xxxv,   171. 

'Borrmann:  Deutsch.   Zeitschr.  f.   Chir.,   1906,   Ixxxii,  .36.3. 

8  Von  Brunn:  Zentralbl.  f.  Chir.,  1907,   xxxiv,  550. 

"Steiner:  Deutsch.  Zeitschr.  f.  Chir.,  1906,  Ixxxii,  363. 

1"  McGlannan:  Maryland   Med.   Jour.,  July  and  August,   1908. 

"Volkmann:   Samml.  klin.  Vortr.  Chir.,   1889,  No.   102. 

i-Hazen:  Jour.  Amer.  Med.  Assn.,  1915,  Ixiv,  658;  Southern  Med.  Jour.,  1915, 
viii,  577. 


CHAPTER  YII. 

BENIGN  AND  .AIA[.IC;XAXT  TUMORS  OF  THE  CUTANEOUS 

APPENDAGES. 

As  has  already  been  pointed,  out,  the  normal  skin  has  the  follow- 
ing appendages:  hair  follicles,  both  of  the  lanugo  and  deep  hairs, 
■with  the  adjoining  sebaceous  glands,  and  the  sweat  glands  and  duets. 
From  all  of  these  organs  both  benign  and  malignant  tumors  may 
arise.  In  addition,  there  is  unquestionably  the  possibility  of  there 
being  congenitally  displaced  epithelial  or  glandular  tissue,  and  it 
now  seems  fairly  certain  that  at  least  one  clinical  and  pathological 
entity,  the  syringocystadenoma,  springs  from  congenitally  misplaced 
coil  ducts.  Dermoids,  of  cour.se,  have  their  origin  in  congenitally 
dislocated  tissue. 

OAving  to  the  degenerative  changes,  as  avcII  as  the  modifications 
in  cell  type,  that  naturally  take  place  during  the  lifetime  of  a  neo- 
plasm, it  is  highly  probable  that  a  fair  number  of  tumors  originate 
from  these  appendages,  and  that  they  cannot  be  diagnosed  as  such 
under  the  microscope.  In  even  a  slightly  advanced  basal-celled  car- 
cinoma, it  is  impossible  to  determine  ■whether  the  origin  was  in  the 
basal  layer  of  the  epithelium  or  in  the  hair  follicle.  As  Unna^  well 
points  out,  the  cells  of  the  sebaceous  glands  so  readily  revert  to  sim- 
ple-appearing epithelial  cells  that  one  might  never  suspect  a  car- 
cinoma of  having  its  origin  in  them.  Fi'om  these  two  illustrations 
it  can  be  readily  seen  that  it  is  often  impossible  to  say  in  just  ■what 
cells  the  malignant  change  first  appeared. 

TUMORS  OF  THE  HAIR  FOLLICLES. 

The  hair  follicle  has  different  layers,  just  as  has  the  skin,  and  epi- 
thelial growths  may  originate  from  any  of  these  layers.  Krom- 
pecher-  states  that  he  has  been  able  to  recognize  two  tumors  of  the 
face  as  springing  from  the  basal  layers  of  the  hair  follicles,  and 
various  other  pathologists  have  reported  similar  observations.  It  is 
certain  that,  as  our  knoAvledge  and  technic  improve,  we  shall  later 
be  able  to  identify  neoplasms  as  springing  from  some  of  the  numer- 
ous lavers. 


'Unna:  Histopathology  of  Diseases  of  the   Skin,   New  York,   1896. 
=  Krompecher:  Der  Basalzellenkrebs. 

92 


BENIGN    TUMOKS    OF    (JUTANKOCS    AI'l'KNDAOKS.  ')■'> 

At  the  present  time  two  difrereiit  cliiiifal  and  patholo^if'Jil  vari- 
eties of  tiiiiioi'  ai'isinf^  ij-oiii  tin;  ha.sa]  laycir  have  bee)i  fliffer-eiitiated. 
The  finst  is  the  multiple  benign  cyslic  epitheliomd ,  suhv;iri('1y  of 
Von  /ai'iseh,  which  is  clinieally  iiuliHliiif^tiishable  from,  the  iriore 
common  type  known  as  the  lirooke-l^'ordycfv"'  variety,  where  the 
growth  is  from,  the  l)asal  laA'crs  oT  1h(!  cpil  lidiinn  in'opci-.  I'hesc 
tumors  will  be  fully  discussed  in  the  ch;i|)1('r  dcjiliii^  ui1li  llic  inul- 
tiplo  benign  tumoi-s. 

The  second  is  the  rodent  ulcer  type,  or  the  irichoepilJidi.ovui  of 
some  authors. 

The  case  reported  by  Bloodgood*  is  a  fair  illuslrati(jn  of  this  tyjtc. 
It  occurred  upon  the  cheek,  just  anterior  to  the  angle  of  the  jaw, 
in  an  elderly  man,  having  been  present  for  foui'teen  j'ears  as  "a 
small  elevated  area  covered  with  hair,"  probably  a  nevus  of  the  hairy 
type.  During  the  last  year  it  had  grown  to  about  7  or  8  cm.  in 
diameter,  and,  as  the  result  of  the  use  of  a  caustic  paste,  there  was 
a  slight  superficial  ulceration,  with  considerable  induration  at  the 
edge  of  the  solid  portion  of  the  neoplasm.  The  tumor  was  freely 
movable  over  the  cheek  muscles.  It  was  easily  excised  under  cocaine, 
and  it  was  then  found  that  there  was  a  zone  of  normal  fat  between 
the  neoplasm  and  the  underlying  muscles.  At  the  end  of  fourteen 
years  there  had  been  no  recurrence.  On  section  of  the  tumor  the 
gross  appearance  showed  large  hair  follicles,  containing  hairs  in  the 
depth  of  the  tumor.  Between  the  follicles  the  normal  tissue  was  re- 
placed by  "a  firm,  white,  granular  tissue,  divided  into  alveoli  by  a 
firm  connective  tissue  stroma.  Here  and  there  were  a  few  ca\'ities, 
containing  finely  granular  material — that  is,  the  naked  eye  appear- 
ance of  an  epithelioma  spinocellulare  malignum. "  Histologically, 
however,  the  cells  w^ere  not  those  of  a  prickle-celled  carcinoma,  but 
more  nearly  resembled  basal  or  cuboidal  cells,  and  in  places  could 
distinctly  be  seen  springing  from  the  hair  follicles. 

In  Bloodgood's  laboratory  the  author  had  the  opportunity  of 
studying  another  case  in  which  the  tumors  were  of  much  slower 
growth,  and  in  which  the  cells  were  distinctly  basal  in  character. 

Recently  the  author  has  had  a  rather  interesting  case  in  his  own 
practice.  The  patient  was  a  man  of  45,  referred  by  Dr.  Balloch,  who 
had  been  struck  upon  the  head  two  years  previously,  while  on  a 
fishing  trip  in  the  north  woods.  A,  few  months  later  there  developed 
a  nodule,  which  had  slowly  increased  in  diameter.  "When  se«n,  there 
was  on  the  right  anterior  quadrant  of  the  scalp  a  large  growth  that 


^  Sutton;  Jour.  Amer.   Med.   Assn.,   1912,   Iviii,   3o 
*Bloodgood:  Prog.   Med.,  Dec,   1904. 


94 


SKIN'    CANCER. 


closely  rosoinbled  a  typical  rollcd-cdp:c  roilcnt  ulcer.  It  was  at  least 
12  cm.  ill  (.liaiiu'tcr.  the  vd^xo  was  very  hainl.  and  firmly  attached  to 
the  skin,  but  not  to  the  nnderlyinj?  bone.  No  ulceration  had  taken 
place.  The  hair  was  si)arso.  just  as  it  was  upon  the  remainder  of  his 
scalp.  As  oi)eration  would  liave  been  very  difficult  because  of  the 
size  of  the  growth,  it  was  dctenniued  to  try  the  x-ray.  and  the  re- 
sults were  very  jzratifyiny:.  for  the  jji-owth  i)romi)tly  healed  and  for 
over   two   years   there   has   ])ecn   no   recun-ence.      Ilistolo«j:ically,    the 


Fig.   36. — Carcinoir.a  originating  in   hair  follicles.     Low-power  photomicrograph. 

(Author's   collection.) 


picture  was  very  similar  to  Bloodjjood's  case  (Fip:.  36).  There  were 
very  large  hair  follicles  extending  deep  into  the  tissues;  practically 
the  whole  field  was  filled  with  them,  packed  so  closely  together  that 
there  was  no  room  for  any  other  tissues.  The  hypertroj)hy  was  al- 
most confined  to  the  basal  layers,  and  from  some  of  them  escaping 
strands  of  cells  could  readily  be  distinguished.  The  follicles  con- 
tained no  hairs. 

In  addition  to  the  various  types  of  cases  mentioned  above,  it  must 


BENIGN    'I'lJMORS    OK    (JIITA  N IXX  "S    A  I'I'I  NDACKS.  95 

be  borne  in  mind   iliat,  some   of  ilic  lypicul    I'odcnt    uIcits.   o)-   [jasal- 
eellcd  carcinoniatu,  niidoiihlcdiy  orif^inate  in  the,  hair  folliclcjH. 

TUMORS  OF  THE  SEBACEOUS  GLANDS. 

At  leant  four  patlioloj^ical  types  of  tunioi's  may  arise  iJ'fjiii  the 
sebaceous  glands;  (ii'st,  simple  hypertrophy,  which  clinically  may  give 
two  different  conditions — the  well-known  adenoma  sebaceum  and,  in 
addition  to  this,  irregular  nodulations,  often  known  as  rhinophyma; 
second,  true  adenoma  of  the  glands,  which  condition  may  also  be 
found,  in  adenoma  sebaceum  according  to  Sutton  \-'  third,  a  basal- 
eelled  carcinoma;  and,  fourth,  an  adenocarcinoma  ar-ising  from  tlio 
inner  and  more  differentiated  layer  of  lining  cells. 

Adenoma  Sebaceum. — The  sul)ject  of  adenoma  sebaceum  will  be 
fully  discussed  in  the  following  chapter.  Simple  hypertrophy  of 
the  sebaceous  glands  also  appears  at  times  as  an  accompaniment  of 
other  diseases,  and  at  times  as  independent  tumors.  The  independ- 
ent tumors  are  rare;  they  are  isolated,  grow  slowly,  are  yellowish- 
white  in  color,  opaque,  and  usually  from  3  to  6  cm.  in  diameter, 
semiglobular  in  appearance,  but  globular  to  the  palpating  finger, 
and  often  show  a  gaping  follicle.  At  times  sebaceous  material  can 
be  squeezed  from  them.  Much  more  frequent  are  the  hypertrophies 
associated  with  rosacea  and  histologically  combined  with  prolifera- 
tion of  the  fibrous  tissue.  This  condition  usually  occurs  upon  the 
nose,  but  may  to  a  slighter  extent  involve  the  che^^ks  and  forehead. 

True  Adenoma  of  the  Glands. — True  adenoma  of  the  glands  are 
practically  unknown  according  to  Unna.  but  Sutton  thinks  that  in 
one  of  his  cases  of  adenoma  sebaceum  he  is  justified  in  considering 
that  this  condition  was  present. 

Basal-Celied  Carcinoma. — As  Kronipeeher  points  out,  the  basal 
cells  of  the  skin  form  an  unbroken  line  with  the  basal  cells  not  only 
of  the  hair  follicles,  but  Avith  those  of  the  sebaceous  glands  as  well, 
so  that  a  priori  there  is  reason  to  believe  that  basal-celled  tumors 
may  originate  from  them ;  he  offers  no  proof,  however,  that  such 
neoplasms  do  exist.  Thiersch  thought  that  very  many  of  the  cyl- 
indroma (epithelioma  basocellulare  adenoides)  had  their  origin  in 
the  sebaceous  glands,  but  his  deductions  were  founded  entirely  upon 
the  fact  that  the  arrangement  of  the  cells  in  this  condition  resembled 
the  arrangement  of  the  cells  in  the  sebaceous  glands,  and  that  the 
lobular  shape  of  the  two  was  somewhat  alike :  hence  his  views  were 
speedily  oveli:hroA^^l.     It  must  be  remembered  that  a  tumor  could 


'Sutton:  Jour.   Cutan.   Dis.,   1911,  xxix,   4S0. 


i)l)  SKIX    CANCER. 

easily  originate  fi'Diu  these  eells,  and  that  after  a  slight  period  of 
time  it  would  be  inipossil)le  to  prove  or  even  suspeet  this  fact.  While 
this  faet  is  by  no  means  jirovcn.  yet  the  author  feels  convinced  that 
such  must  be  the  case. 

Adenocarcinoma. — Uinia  states  that  one  of  his  seventy-three  cases 
arose  from  the  sebaceous  glands,  and  still  retained  the  character- 
istics of  the  sebaeeous-eell  type.  He  calls  particular  attention  to 
the  fact  that  in  any  inflammatory  or  neo])lastic  condition  the  cells 
lose  their  fat,  and  revert  to  a  simple  cuboidal  epithelial  type,  im- 
possible to  differentiate  from  other  epithelial  eells.  Bloodgood  men- 
tions none  of  his  tumors  as  of  this  class.  Nor  is  any  of  the  recent 
literature  helpful  on  this  class  of  tumors.  Kecently  the  author  has 
seen  a  remarkable  case  of  adenocarcinoma  of  the  sebaceous  glands 
where  the  cell  type  was  completely  retained  (Fig.  37).  The  patient 
was  a  middle-aged  negress,  admitted  to  the  surgical  service  of  the 
Freedmen's  Hospital  Ijecause  of  a  f ungating  tumor  that  had  ex- 
isted upon  her  left  buttock  for  one  year.  She  stated  that  it  had 
started  as  a  nodule  beneath  the  skin,  which  had  rapidly  grown  and 
speedily  ulcerated.  On  examination  a  large  part  of  the  buttock  was 
involved  by  a  deeply-seated  tumor  that  had  ulcerated  through  the 
skin  and  become  markedly  fungous.  In  the  nearby  skin  were  sev- 
eral similar  smaller  neoplasms.  The  left  inguinal  glands  were  mark- 
edly enlarged.  On  biopsy  it  was  found  that  the  tumor  consisted  en- 
tirely of  enormously  enlarged  and  dilated  sebaceous  glands,  more 
or  less  filled  with  an  albuminous  material.  The  lining  cells  were 
but  one  or  two  rows  thick,  and  had  retained  all  of  the  characteristics 
of  sebaceous  gland  cells.  A  few  of  the  cells  had,  however,  escaped 
through  the  ba.sement  membrane.  There  were  numerous  mitotic  fig- 
ures. All  of  the  cells  contained  fat,  and  were  of  the  same  size  and 
general  characteristics  as  normal  gland  cells.  Unfortunately  the  pa- 
tient refused  operation  and  Avas  lost  sight  of. 

TUMORS  OF  THE  SWEAT  GLANDS. 

Here,  again,  there  are  several  possibilities:  First,  simple  hyper- 
trophy of  the  sweat  glands;  second,  true  adenoma  of  the  sweat 
glands;  third,  basal-celled  carcinoma  of  the  sweat  glands;  and  fourth, 
more  malignant  carcinoma,  springing  from  the  lining  cells  of  the 
sweat  glands. 

Simple  Hypertrophy  of  the  Sv^reat  Glands.— Simple  hypertrophy 

of  the  sweat  glands  does  not  form  tumors,  so  far  as  is  now  recog- 
nized. 


BKNIGN    TUMOKS    OV    (MJTANKOI  S    A  I'I'I;\I)A(;KS. 


07 


True  Adenoma  of  Sweat  Glands.-Uima  stales  IIimI  do.iuuUt  ad- 
enomata  of  the  coil  ^UuuIh  -.uv.  very  rare,  ami  thai,  most  lurnors 
usually  supposed  to  consist  of  these  elements  arc  m  reality  derived 
from  the  sweat  duets.  As  .,  erilerio..,  it  is  m^eessary  to  show  th.d, 
lateral    f^rowths   spring   from   the   ^hinds.   tli-'se   ;,rowths  tending  to 


Fig-  37 -This  carcinoma  of  the  buttock  arose  about  one  year  ago.  and  is  now 
practically  inoperable,  owing  to  a  mass  of  glands  in  the  grom.  Histological 
examination  showed  that  the  neoplasm  still  retained  the  structure  of  the  sebace- 
ous glands,  from  which  it  arose.  This  proves  that  an  adenocai-cinoma  of  the 
skin  may  metastasize  rapidly,  and  that  the  glands  should  be  taken  out  at  the 
earliest  possible  moment.      (Author's   collection.) 


98  SKIN    CANCKH. 

bend  and  roll  up ;  the  presenec  or  absence  of  a  lumen  is  of  no  par- 
ticular moment,  but  the  basal  membrane  must  be  intact.  The  true 
cases  of  spiradenoma  fall  into  two  irroujis,  according  to  uhether  they 
form  true  independent  tumoi's.  or  are  sim])ly  accoin])animents  of 
other  dermatoses.  The  former  are  rare,  the  latter  fairly  common. 
The  latter  type  is  most  fre(iuently  encountered  in  association  with 
carcinomata  and  an«!:iomata.  also  in  lupus  .md  uciirolihi'oinala,  as 
well  as  varices  of  the  leg. 

Unna  has  collected  six  cases  wliicli  he  accepts  as  Irue  spii-adcno- 
mata — the  cases  reported  by  Lotzbcck,  Thierfelder,  Knauss,  Chande- 
lux,  the  llaggans.  and  one  of  his  own.  Most  of  these  tumors  arose 
as  subcutaneous  nodules,  which  grew  either  slowly  or  rapidly,  but 
which  were  always  encapsulated.  Usually  there  W'as  considerable  ac- 
companying vascular  dilatation.  T'nna's  review  of  tlies(>  ca.ses  is 
very  complete. 

Adenocarcinoma  of  Sweat  Glands. — Cai-eintniiala  of  llie  sweat 
glands  are  coiiipara1i\ely  rai-e  tumors,  and  must  usually  be  de- 
rived from  the  basal  cells,  for  they  are  of  comparatively  slow 
growth.  They  arise  as  nodules  beneath  the  skin,  -which  gradually  be- 
come adherent  to  the  surrounding  tissues  and  eventually  ulcei-ate. 
Bloodgood  has  seen  but  two  cases.  His  second  case  is  described  as 
follows:"  "It  w^as  observed  in  a  colored  Avoman  aged  50  years.  Two 
years  ago  attention  was  called  to  the  back  by  itching;  the  patient 
felt  a  small  nodule  in  the  back,  about  the  size  of  a  bean,  since  which 
time  there  has  been  a  steady  growth,  and  the  patient  has  abraded 
the  surface  by  constant  scratching.  .  .  .  The  central  ulcera- 
tion is  very  superficial,  like  an  abrasion,  and  covered  with  a  brown- 
ish crust.  This  ulceration  occupied  the  center  of  an  oval,  with  a 
slightly  elevated  area  of  induration  not  sharply  outlined  from  the 
surrounding  tissue.  Clinically,  it  appeared  like  a  diffuse  fibroma 
of  the  skin,  which  is  not  an  uncommon  ol)servation,  especially  in  the 
colored  race.  .  .  .  On  section  l)etween  the  superficial  ulcerated 
area  and  the  surrounding  zone  of  epidermis,  one  could  see  nothing 
but  a  diiYuse  growth  of  fibrous  tissue.  Epithelial  alveoli  could  not 
be  distinguished  with  the  naked  eye;  yet,  when  .studied  mieroseopi- 
callj',  this  fibrous  stroma  was  riddled  with  minute  areas  lined  or 
filled  by  sweat  gland  epithelium,  and  in  many  places  the  long  tubules 
of  the  sweat  glands  were  preserved."  With  all  due  deference  to 
the  great  authority  of  Bloodgood,  the  author  feels  tliat  1liis  tu- 
mor is  an  exniiiple  of  an  adenoma  of  the  sweat/lucts,  I'allici-  than 


•Bloodgood:  Prog.  Med.,  Dec,  190-1. 


Bi<:Nf(JN    'J'lJMOKS    OF    rMITA  NKOI 'S    ,\  I'I'KXDAOKS. 


09 


H  c;u'('.iii<)Mi;i,  of  the  ,^l;iii(ls.  In  ;i  I'cccnl  ;irlic|c  Wol  riicim^  states 
that  thcM'c  Jii'c  but  fwd  ccrlnin  ciiscs  of  this  disease  mi  I'eeoivl — a  fiawc 
of  Darier's  ujkI  ojk;  of  liis  own.  Wul  I'lieim  eonlends  1liai  the  fol- 
lowing criteria  are  necessary  in  orcler  1(»  eslahlisd  heyond  all  fjoubt 
this  diagnosis:  first,  either  a  sure  eoiin(;ction  willi  llie  duels  or  coil 
glands;  second,  a  nior})h(jl()gy  vvliicli  can  ])e  idenlifiefj  without  any 
doubt  as  normal  or  abnormal  sweat  glands;  and  1liir<l,  Ihc  condition 
of  the  elastic  tissue  must  be  investigated,  because  its  characteristic 
arrangement  around  the  tumor  mass  indicates  whether  we  have  to 
do  with  sweat  gland  tissue.  Klaubcr^  has  given  an  excellent  review 
of  the  subject. 


yfer\.  iki-  'w.>.iA£a:iL>.-'i2. 


Fig.   38. — Low-power 


photomicrograph   of  adenoma   of  the   sweat  ducts.      (Author's 
collection.) 


TUMORS  OF  THE  SWEAT  DUCTS. 

Here  also  there  are  several  possibilities — first,  benign  tumors  of 
the  ducts,  and,  second,  carcinomata  arising  from  the  ducts.  Also, 
it  must  be  remembered  that  the  multiple  syringocystadenomata  spring 
from  congenitally  displaced  sweat  ducts. 

Benign  Tumors  of  the  Ducts. — The  benign  tumors,  or  syringo- 
adenomata,  are  usually  solitary,  or  occasionally  multiple  tumors,  and 


■Wolfheim:  Arch.  f.  Dermat.  u.   Syphil.,  1907,   Ixxxv,   277. 
sRlauber:  Beitr.   z.   khn.    Chir..   1904.   xli.   311. 


100 


SKIS'    CANCKK. 


are  apt  to  appoar  iipun  the  face  as  seiiiiglulnilar  nodules,  wliich  on 
palpation  are  easily  ilistin^uished  as  fjlobular,  but  Mhieh  arc  not 
adherent  to  surrounding;  tissue.  They  vary  in  diameter  from  1  to 
8  cm.  llistolofjically,  they  consist  of  many  latei-al  branches  from 
the  ducts,  the  lumens  of  which  may  or  may  not  be  patent,  but  the 
basal  membrane  of  which  is  never  broken  throuj^h.  Besides  the  in- 
crease of  epithelial  tissue,  there  is  an  increase  of  fibrous  tissue  as 
McU  (Figs.  38,  39). 

Petersen  has  described  a  case  of  clinical  '■nevus  nnius  lateralis" 
which  consisted  chieflv  of  a  true  syringoadcnoma,  and  Unna  has  had 


X 


Fig.    39. — Adenoma  of   sweat   ducts.      High-power   pliotomicrograph.      (Author's 

collection.) 


a  somewhat  similar  case,  and  which  he  dcscri])cd  as  "asphyxia  reti- 
cularis multiplex." 

Carcinomata  of  the  Ducts. — Carcinomata  of  the  ducts  have  not 
been  described,  but  doubtless  occur. 

Treatment. — The  treatment  of  all  of  these  tumors  is  faii-ly  def- 
inite. When  a  tumor  is  clinicallj''  benign,  it  may  be  treated  by  sim- 
ple excision,  and,  when  clinically  malignant,  by  broad  local  removal, 
usually  without  disturbing  the  lymph  glands.  If,  however,  micro- 
scopical examination  shows  a  malignant  type  of  carcinoma,  the  glands 
should  be  removed  at  once.     If  good  frozen  sections  can  be  obtained 


BENIGN    TUMORS    OF    CUTANKOUS    AI'l'i;.\I).\GJ':.S.  301 

at  once,  this  furtlior  operation  may  Ijc  flonc  ;i1,  Uk:  s;inic  siHirif.',  as 
otherwise  a  second  operation  is  necessary.  Jji  jijf>[)ci;il»lc  fases  one 
might  resort  to  radium,  the  x-ray,  or  the  curette  jukI  (•;iiiir;ry.  Ir- 
ritant pastes  shoukl  never  ])e  used,  for  tlu;  ^mtiwHi  is  usiuilly  loo 
deeply  situated  to  ;i.l]ovv  of  curative  results. 


MULTIPLE  BENIGN  TUIMORS. 

The  thi'oo  varieties  of  iiuiltiple  hciiiuii  liiiuoi's  of  ciiitliclial  orif^nn 
— namely,  the  multii)le  benign  eystic  ciiitlu  lidiiia.  Ilic  syringoeyst- 
adenonia,  and  adenoma  sebaceum — havi'  i-i'ci'Utly  been  thoronf;hly 
studied  l)y  Sutton/  and  the  foHowinfj:  account  is  hirgely  derived  from 
his  ai'tieles. 

MULTIPLE  BENIGN  CYSTIC  EPITHELIOMA. 

These  tumors  witc  lii-st  studied  liistoh)iii<'all\  by  bialzer  and 
Menetrier-  in  1885,  but  they  failed  to  recoj;nizc  the  true  nature  of 
the  {2:i-o\vths.  Brooke^  in  1892  and  Fordyee''  in  the  same  yeai*  inde- 
pendently investij;ated  the  lesions  and  arrived  at  a  itroper  solution 
of  the  problem. 

Clinical  Course. — Clinically,  the  disease  is  more  apt  to  oc- 
cur ill  \vomen  (Fig.  40),  usually  those  past  middle  life,  and  there 
is  a  marked  tendency  for  the  disease  to  run  in  families,  several 
members  frequently  being  involved.  The  site  of  ])redilection  is  the 
face.  The  tumors  are  translucent  and  vary  in  size  from  2  to  8  mm. 
ill  diaiiieter.  They  vary  in  nuniber  from  six  to  twenty.  I'sually 
the  growths  remain  stationary  for  many  years,  a  few  new  ones  oc- 
casionally appearing,  but  the  older  ones  showing  no  tendency  to 
either  enlargement  or  to  spontaneous  disappearance.  In  a  few  cases 
malignant  change  has  taken  place,  this  having  occurred  in  the  cases 
reported  by  J.  C.  White,"'  Jarisch."  Stclwagon,'  Sutton  and  Dcnnie,"* 
and  Strobel."  Heidingsfeld'"  is  inclined  to  l)elieve  that  all  tumors 
of  this  class  are  premalignant  in  both  structure  and  character,  but 
Sutton  stronglv  dissents  from  this  view. 


'Sutton:  Jour.   Amer.  Med.   Assn.,   1912,   Iviii,   333. 

Jour.  Cutan.  Dis.,  1911,  xxix,  480. 

Amor.   Jour.    Med.    Sc,    1913,    cxlv,    819. 
=  Balzer  and   Menetrier:  Arch.    f.   Physiol.,   1885,    565. 
»  Brooke:  Brit.   Jour.    Dern:at.,   1892,    iv,   269. 
«Fordyce:  Jour.  Cutan.  Dis.,  1892,  x,  459. 
5  White:  Jour.  Cutan.  Dis.,  1894,  xii,  477. 
•Jarisch:  Arch.  f.  Dermat.  u.  Syphil..  1892,  269. 
'Stelwagon:  Di-seases  of  the  Skin,  Phila.,  1910. 
*  Sutton  and  Dennie:  Jour.   Amer.  Med.  Assn.,   1912,  Iviii.   333. 
«  Strobel:  Personal  communication. 
"Heidingsfeld:  Jour.    Amer.    .Med.   Assn.^    1912.    Ivix.    256. 

102 


MUJ/1'II'M: 


l<;.\   'I  I  MOi;,-. 


lO:; 


Pathology. — TTistoloj,no;illy,  llici-c  ;itc  two  flisliiift,  typos — the 
Brooke  type,  wlici-e  the  luinor  is  dcriviMl  fiDMi  thf  Ijusal  layers  of 
the  rete,  and  the  .Ijiriscli  tyfx;,  where  1lic  iifolilVrjiliori  is  from  the 
hair  follieles.  In  both  types  1hc  piciuic  is  soinewhat  similar,  for 
^'extcndinf^  down  into  the  foriiim  rrom  tlic  l);is;il  l;i>-f'r  were  numer- 
ous fine,  long,  slender  cluiins  of  cftil  liclinm,  Iwo  oi'  1hr(!e  cells  in 
width,  whieh  terminated  in  hiilh-like  eysts,  filled  wilh  folloid  ma- 
terial and  corneous  niateriid."  These  collections  of  horny  matter 
are  undoubtedly  snared  off  from  the  horny  layer,  as  so  well  illus- 
trated by  Krompechcr  in  examples  of  the   basal-celled  tumors.     In 


Fig.  40. — Multiple  benign  cystic  epithelioma.     (C.  J.   White's  collection.) 


some  cases  there  is  an  additional  subdividing  of  the  downgro^^i:hs. 
In  addition  to  these  changes,  cysts  are  found  in  the  upper  portion 
of  the  prickle  layer,  tilled  with  hornified  material.  There  may  be 
a  considerable  amount  of  small  round  infiltration  in  the  corium  (Fig. 
41). 

Nomenclature. — Inasmuch  as  the  cells  are  distinctly  basal  in  char- 
acter, the  author  feels  that  the  name  proposed  by  Unna^^  and  adopted 
by  Sutton — namely,  Aca)if]io})ia  adcnoidcs  cysfkum — is  an  unfor- 
tunate one,  for  the  term  acanthoma  should  refer  entirelv  to  tumors 


^^Unna:  Histopathology  of  Diseases. of  the  Skin. 


104 


SKIN    CANCER. 


derived  from  the  prickle  layer.  The  name  BasoccUidomu  adcnoidcs 
cysticum  would  be  nearer  the  correct  term,  and  only  the  disinclina- 
tion to  further  incumber  the  dermatological  nomenclature  prevents 
the  author  from  adopting  it. 

SYRINGOCYSTADENOMA. 

This  group  has  likewise  l)ceii  well  studied  Uy  Sutton,  and  his  find- 
ing confirmed  l)y  Welch.  For  tliis  group  of  tumors  there  have  been 
many  names  proposed,  largely  l)ocause  of  the  uncertainty  as  to  the 


true  pathological  picture.  It  has  been  repeatedly  confused  Avitli  the 
group  just  described.  Biesiadccki^-  and  Kaposi^^  called  these  growths 
"Lymphangioma  tuberosum  multiplex;"  Quinquad,''  "Cellulomc  cpi- 
theliale  eruptif;"  Besnier,"  "Nevi  epitheleaux  cystiques;"  AVald- 
heim,^^  "Hemangioendothelioma  cutis  papulosum;"  and  Gassmann," 


"  Biesiadecki:  Untersuchungen  aus  clem  path.  ii.  anat.  Inst,   im  Krakau,   1872,  2. 
"Kapo.si:  Hebra's  Lehrbuch  der  Hautkrankheiten,  Enke. 
"Quinquad:  Trans.   Internat.    Congr.   Dermat.,   Paris,   1889,   412. 
"Besnier:  Besnier  and  Doyen's  Translation  of  Kaposi  Pathol,   u.   Therapie   der 
Hautkrankheiten,    ii.   367. 

"Waldheim:  Arch.  f.  Dermat.  u.  Syphil.,  1002,  225. 
'•Gassmann:  Arch.   f.   Dermat.  u.   Syphil.,   1901,  Iviii.   177. 


MiJi/i'iri,!';  iii:Ni(;.\  timoks. 


105 


"Ncvi  cyst-ci)itli('li()in}ilo.si  |»;i|>nl(isiiiii."     In  iidililion  U)  thoso  names, 
many  others  have  been  ^iveii.  from  time  to  time. 

Clinical  Course. — (Jlinieally,  these  tumors  appear  as  numerous 
translucent  scmiglobular  j^n-owths  (F'v^.  42),  varying  in  diameter  from 
2  to  8  mm.,  and  usually  situated  on  oithei-  the  chest  or  face.  Women 
appear  to  be  more  subjeet  to  them  1li;iii  do  men.     They  persist  in- 


Fig.  42. — Syringocystadenoma.      (Sutton's  collection.) 


definitely,  neither  growing  in  size,  nor  tending  to  disappear.     They 
do  not  undergo  malignant  change. 

Pathology. — Pathologically,  the  stratum  corneum  is  unchanged 
(Figs.  43,  44),  the  granular  layer  is  somewhat  thinner  than  normal 
and  is  devoid  of  granules,  and  the  basal  layer  is  regularly  arranged, 
but  the  cells  are  swollen  and  edematous,  and  the  nuclei  large  and 
vesicular.  The  papillfe  are  flattened,  or  perhaps  lacking.  There  is 
some  cellular  infiltration  in  the  upper  portion  of  the  corium,  but 
the  blood  vessels  are  lessened  in  number  and  show  no  iirflanimatory 
changes,  the  capillary  endothelium  being  normal.  The  elastic  tis- 
sue is  reduced  in  amount,  and  an  elastic  membrane  completely  sur- 


100 


SKIN    CANCEK. 


rounds  the  cysts.  Hair  follicles  aiul  scl)accous  p:laiuls  ai)poar  to  be 
iiorinal.  The  coil  jilaiuls  are  well  (levelo|)ed  aiul  exhibit  no  patho- 
logical changes.  There  is  some  coUnu^cnous  degcnei'atioii  of  the  con- 
nective tissue  stroma.  Scattercil  tlirou^lmut  the  cutis,  from  the  sub- 
papillary  poi'tion  of  the  corium  to  the  subcutaneous  fat,  are  num- 
bers  of   round   or   o\al    masses   of   ei)itheliuiii    niid    e|)ithclial    IIiumI 


# 


.-^ 


^ 


•V-    .^^ 


■  ■>' -:> V«J>  J*^  >fa  ."'   ■■   '    '  • 


Fig.  4.'?. — Low-power  photomicrograph  of  syringocystadenoma.     (Sutton's  collection.) 

tubules.  ]\lany  of  these  cell  collections  ])osscss  a  stem-like  api)eiidage 
of  epithelial  cells,  two  cells  in  thickness,  which  connect  two  or  more 
of  the  gland-like  masses.  In  many  in.stances  these  epithelial  tracts 
are  found  existing  through  the  corium.  The  nuclei  of  the  cells  is 
large  and  stains  deeply.  In  maeroscopically  normal  skin  taken  from 
the  trunk  Sutton  has  found  similar  strands  of  epithelial  cells,  and 
in  one  specimen  several  budding  processes  and  a  few  cysts  were  pres- 
ent. That  these  cells  still  retain  their  function  was  proven  by  Sut- 
ton by  administering  pilocarpine  to  the  patient,  sweat  appearing 
upon  the  surface  of  the  tumors. 


MIJI/l'Il'l.i:   HKNIOK   'J'U.VHMtS. 


107 


Origin. — There  is  still  ;i  qiicsiioii  ;is  1o  wiicllicr  1li(!S(;  lunioi's 
spi'iti;^'  fi'oin  pi'eviously  nonnnl  s\\c;i1,  (iiicts,  or  from  congenital  or 
ac([nir('(l  defeets.  Tiiriik'^  holds  lli;it  I  he  iihscnfc  or  rare  occurrence 
of  Kwcjil  glands  in  tin;  area,  of  Ihc,  tiiiiior,  conipared  to  the  number 
in  the  adjoininfr  normal  skin,  is  indicative  of  the  transformation  of 
the  preexisting  sweat  tiihnles  in1o  tumor  elements.  In  favor  of  the 
congenital  theory  is  the  oeeiirrenee  in  so  many  instances  of  the  tu- 
mor in  early  life,  and  especially  in  several  members  of  the  same 
family.  Schidachi'-'  has  pioduccd  similar  cysts,  even  vv^ith  epithelial 
strands,  by  occluding  the  sweat  ducts.  Stockmann-"  has  shown  that 
the  sweat  tubules  contain  genuine  secretion,  and  in  one  of  Sutton's 
cases  there  was  an  enlai-gement  of  llie  tumor  following  the  use  of 


Fig.  44. — Low-power  photomicrograph  of  syringocj'stadenoma.     (Strobel's  case.) 

pilocarpine.     Sutton  strongly  contends  that  the  growths  are  derived 
from  eongenitally  misplaced  sweat  ducts. 


ADENOMA   SEBACEUM. 

According  to  Sutton,  Kayer-^  was  the  first  to  describe  adenoma 
sebaceum,  calling  it  "Vegetations  vasculaires. ' '      A  few  years  later 


isTorok:   Monatshefte  f.    prakt.   Dermat..    1SP2.  xiv.   1S5. 
1"  Schidachi:  Arch.  f.   Dermat.   u.    Syphil..   1907.  Ixxxiii,   3. 
=»  Stockmann:  Arch.   f.    Dermat.   u.    Syphil.,    1908,   xlii.    145. 
=iRayer:  Rayer's  Treatise,   2d  ed..  Willis's  Translation.  996. 


108 


SKIN    CANCKK. 


AJaison  ami  Gull--  consiaorea  it  to  bo  a  liehou.  In  1800  Prin^'lc=^ 
aceurately  described  the  histolog:}'  of  the  lesions,  and  1yi)ical  cases 
are  often  called  the  "Pringle  type"  of  adenoma  siliacciun. 

Clinical  Course. — The  lesions  are  not  often  seen  in  private  prac- 
tice, and  are  only  exceptionally  encountered  in  the  dispensary,  but 
Crocker-*  states  that  in  insane  asylums  j^lenty  of  them  can  be  ob- 
served. The  lesions  are  discrete,  red  nodules,  varying  in  size  from 
1  to  9  nun.,  and  situated  upon  sides  of  the  nose  and  the  adjacent 
portions  of  the  cheeks  (Fig.  45).     They  may,  however,  be  scattered 


Fig.    45. — Adenoma   sebaceum.      (Author".s   collection.) 


upon  any  other  portion  of  the  face.  The  surface  capillaries  arc  di- 
lated, thus  giving  the  bright  red  color.  The  lesions  tend  to  run  in 
families,  just  as  the  above  described  conditions  do.  A  low  grade 
of  mental  development  not  infrequently  accompanies  the  cutaneous 
condition.  Poor  considers  that  there  is  another  type  of  adenoma  se- 
baceum, in  which  the  eruption  is  asymmetrical,  and  the  lesions  tend 
to  coalesce.  Krzystalowicz  considers  that  there  are  two  pathological 
varieties — one  a  true  hypertrophy  of  the  sebaceous  glands,  which 


=^  Addison  and  Gull:  Guy's  Hospital  Reports,  ser.   2,  vii,   267. 
'^Pringle:  Brit.   Jour.   Dermat.,   1890,  xii,   1. 
"Crocker:  Diseases  of  the  Skin. 


MUi/i'ii'Li';  j{i;ni(;,\  'rtjMfjus. 


109 


may  undergo   deffoncrjilioii,    jind    ;i,   scfoiid    \viiic;h   Hfcnis   to    iofludf; 
pathological  deviations. 

Pathology.- — In  a  roccni  cjisc!  of  SiiHon's,  two  tumors  were  ex- 
cised, and  Ills  report  is  iipitciidcd  in  a,  soincwliat  al)hr(!viated  form. 
The  smaller  growth  was  jnHd(!  up  oT  two  iiriy)(',rf(!ctly  formed  and 
empty  hair  follicles,  with  subjoined  masses  of  enormously  hypei*- 
trophied  sebaceous  glands,  the  birger  ol"  wliieli  eonneeltid  direetly 
with  the  surface.  The  cells  and  uucl(;i  stained  cleai-ly  and  well. 
Two  of  the  larger  masses  of  glandular  tissue  were  divided  into  sep- 
ai-ate  lobules  by  fine,  fibrous  septa.     The  larger  tumor  more  nearly 


Fig.    46. — MoUuscum   contagiosum.      (Author's   collection.) 


fulfilled  Unna's  requirements  for  a  true  steatadenoma  (a  benign  tu- 
mor-like growth  of  irregular  formation,  proceeding  from  the  epi- 
thelium of  the  sebaceous  glands,  in  the  outgrowth  of  which  fatty, 
but  no  colloid  metamorphosis,  takes  place).  Surrounding  the  lower 
third  of  an  abortive  hair  follicle  Avere  numerous  small,  oval,  or  ir- 
regularly oval  collections  of  sebaceous  glands.  No  horny  pearls  or 
colloid  substance  was  found.  The  individual  cells  in  the  sebaceous 
masses  were  smaller  and  less  plump  than  those  observed  in  the 
growth  described  above,  and  the  number  of  the  lobules  was  increased 
threefold.     To  sum  up,  in  one  growth  there  was  a  hypertrophy  of 


110 


-KIN     CANrl.H. 


the  sebaceous  tissiu\  and  in  the  otlun-  the  formation  of  now  fjhancls. 
In  one  case  that  tlio  author  lias  ])orsonally  studied  the  seliaceous 
ghinds  were  but  very  sliijlitly  hypi-rtrophieil,  tlu'  blood  vessels  were 
dihited.  and  there  was  considciable  ])erivaseular  iiililt ration  in  the 
upper  portion  of  the  coriuiii. 

Atypical  Multiple  Growths.-  The  aixive  <lcscriptiuns  arc  char- 
acteristic of  the  typical  j^rowtlis,  but  various  authors  have  described 
various  atyjiieal  nudtiplc  irrowtlis  of  a  bcnitrn  naliiic.  and  clcai-ly 
of  an  ei>ithelial  orijjin.  llartzcll-"'  has  reporteil  a  uniipic  neoplasm 
which  resembled  both  the  niultii)le  benign  cystic  epithelioma  and 
the  syringocystadenoma,  and  which  may  have  been  a  combination  of 
the  two.  Ormsby-'"  has  reported  a  case  of  comparatively  large  tu- 
mors in  which  spontaneous  involution  took  place,  and  which  clearly 
sprang  from  the  sweat  ducts,  which  were  filled  with  and  surrounded 
by  thick  masses  of  epithelial  cells. 

Diagnosis.- — There  are  comjjaratively  fe^v  conditions  wliidi  sim- 
ulate these  multipb'  benign  epithelial  growths.  One  condition  that 
nuist  be  excluded  is  molluscum  contagiosum  (Fig.  46)  and  another 
colloid  milium.  The  former  of  these  comes  on  suddenly,  and  often 
occurs  in  e]iidemies.  There  is  a  marked  central  depression,  and,  on 
opening,  gelatinous  material  can  be  squeezed  out.  Colloid  milium 
usually  develops  upon  the  upper  part  of  the  face,  there  is  no  dila- 
tation of  the  surface  capillaries,  and  the  lesions  arc  distinctly  yel- 
lowish in  color. 

Prognosis. — The  prognosis  is  good  so  far  as  life  is  concerned, 
but  tlie  lesions  persist  indefinitely. 

Treatment. — All  of  these  tumoi's  can  be  i-emoved  by  the  knife, 
curette,  caustics,  electrolysis,  and  at  times  by  the  x-ray.  Personally, 
the  author  prefers  the  electric  needle. 


"  Hartzell:   Brit.   Jour.    Derirat..   19ii4,   xvi,   3G1. 
=«Ormsby:  Jour.  Cutan.   Dis.,   1910,  xxviii,   433. 


CIIAPTi:il    IX. 

NEVOCARCINOMATA  AN])   lAFALKIXAXT   M  KLAXO.M  ATA 
( MALIGNA  NT  PIG  M  KNT  Kl)  M  o  I  >  I-;  S  ) . 

It  is  a  rathei.'  curious  fact  that,  Jilthouj^li  it  lias  been  kncnvn  for 
many  years  that  the  most  malignant  of  all  tumors  spring  from  the 
skin  and  arc  deeply  pigmented,  yet  only  within  the  last  ten  years 
has  the  significance  of  that  fact  been  generally  recognized.  In  1903 
Keen^  and  Bloodgood,"  independently,  showed  that  these  growths  al- 
most always,  if  not  invariably,  spring  fi-oin  moles  or  nevi,  and  rec- 
ommended that  such  growths  be  removed  as  a  prophylactic  measure. 

In  dealing  with  the  clinical  forms,  it  is  wise  to  bear  in  mind  the 
v/ords  of  Unna,^  who  states:  "Since  the  melanocarcinomata  of  the 
skin  always  take  their  origin  in  pigmented  moles,  and,  on  the  other 
hand,  there  can  hardly  be  nevocarcinomata  completely  without  pig- 
ment, it  is  well  to  describe  together  these  two  gi'oups  of  tumors, 
which  are  combined  by  gradual  transitions.  And,  further,  in  every 
other  aspect,  the  character  of  the  two  is  the  same.  In  all  cases  we 
are  dealing  with  rapidly  growing,  pigmented  carcinomata,  of  alveolar 
structure,  which  soon  lead  to  infection  of  the  lymphatic  glands,  to 
more  or  less  melanotic  metastasis  and  a  fatal  termination." 

Clinical  Course. — Clinically,  these  tumors  have  their  origin  in 
nevi,  using  the  term  in  its  broad  sense,  most  frequently  from  either 
congenital  or  acquired,  almost  flat,  deeply  pigmented  moles  of  the 
nonhairy  variety.  It  is  usually  noted  that  a  mole,  usually  one  that 
has  been  subjected  to  trauma,  begins  either  to  grow  or  to  ulcerate, 
these  changes  usually  not  being  especially  marked.  ^letastases  fre- 
quently develop  before  any  change  has  been  noted.  The  general  im- 
pression among  the  profession  seems  to  be  that  these  metastases  usual- 
ly involve  the  skin  and  the  viscera,  and  that  the  lymph  glands  are 
spared,  but  this  view  is  by  no  means  the  correct  one.  for  in  the  vast 
majority  of  instances  there  is  marked  glandular  involvement.  Clin- 
ically there  are  four  main  courses,  which,  of  course,  grade  off,  one 
onto  the  other.  First,  it  may  be  noted  that,  very  soon  after  changes 
are  noted  in  the  mole  (or  nevus),  numerous  other  pigmented  spots 
make  their  appearance  in  the  skin,  looking  very  much  like   other 


iReen:  Jour.  Amer.  Med.  Assn.,  1903. 
-Bloodgood:  Progressive  Medicine,  Dec,  1903. 
'Unna:  Histopathology   of  Diseases   of  the   Skin. 

Ill 


112 


SKIN  r\Nrr:n. 


Fig.  47. — This  figure  show.s  widespread  cutaneous  metastases  from  a  malignant 
pigmented  mole  (nevocarcinoma).  There  were  also  visceral  growths.  (J.  W. 
Perkin's  collection.) 


moles  (Figs.  47,  48).  They  usually,  however,  grow  rather  rapidly; 
some  of  the  glands  begin  to  enlarge ;  a  number  of  fairly  large,  more 
or  less  pigmented,  tumors  appear  on  or  in  the  cutis,  and  signs  of 


NEVOCARCINOMA'IA    AND    MALKiXANT    .M  l.l>A  NO.M  ATA. 


11:5 


viseci'jil  (lisl  iii'l);iii('(!  jirlsc,  i'roiw  wliidi  llic  |»;ilicii1  s[)C(!flily  dicH.  Sec- 
ond, there  may  he;  innrkcd  evidence  oi'  inclasljisis  in  some  of  the  iri- 
tern<al  organs,  nsnnlly  the  livei',  and  l)Ut  i'ew  fn1;incou,s  HyrriptoiriK; 
tliere  ni;iy  or  iiuiy  not  l)c  <^!;indnl;ir  enlargenienl.  Tliiiil,  Ihcre  iriay 
bo  very  marked  involvcnicnt  of  the,  iieighl)orin<4'  j^hinds,  without  any 
other  signs  of  troiil)lc  Ihan  the  changes  in  the  mole.  As  a  genei'al 
rule  in  this  ty|)e,  tlie  liinior  growth  ;it  llie  site  of  thi-  mole  is  com- 
paratively large.      These   cjises    ni;iy    li\c    for    ;i    Miimher   of   years. 


Fig.  48. — Two  years  ago  this  patient  had  an  ordinary  pigmented  mole  on  his  back 
that  was  irritated  by  his  suspenders.  It  has  now  become  malignant,  and  has 
recurred  in  spite  of  an  extensive  operation.  There  are  also  malignant  growths 
in  the  skin  and  viscera.      (Heidingsfeld's   collection.) 


Fourth,  involvement  of  the  glands  does  not  become  apparent  for  a 
number  of  years,  and  further  extension  is  but  sIoav.  The  tirst  three 
forms  do  not  require  to  be  proven  by  illustrations,  but  the  last  t^^pe 
is  sufficiently  rare  to  merit  a  case  report.  The  patient  "was  a  -woman 
aged  50,  who  entered  the  Johns  Hopkins  Hospital,  with  the  follow- 
ing histor.v.     She  was  a  farmer's  wife  from  ^larvland.  and  had  an 


114  SKIX    CANCER. 

ordinary  deeply  ]iigmented  mole  upon  her  forearm,  that  was  one 
day  iH'cked  by  a  hen  so  as  to  bleed.  Several  months  later  the  mole 
bejyan  to  gvo\\\  and  sli<!:ht  ulceration  be«ran  to  manifest  itself.  The 
growth  was  excised  by  a  local  i)hysician.  Almo.st  a  year  later  local 
recurrence  took  plaee.  and  this  was  again  excised.  Two  years  later 
there  was  another  recurrence,  and  there  was  wide  operative  removal ; 
at  the  same  time  a  number  of  enlarged,  deeply  ]ugmented  glands 
were  taken  out  from  tlie  lower  portion  of  the  axilla.  Two  years 
later,  or  five  years  from  the  apinaraiu-e  of  the  original  trouble,  there 
was  an  inoperable  recurrence  in  the  axilla.  In  this  case  early  am- 
putation, or  possibly  a  complete  removal  of  the  nxillai-y  glands,  would 
have  saved  the  life  of  the  patient. 

These  growths  are  especially  liable  to  show  themselves  in  certain 
localities.  They  may  appear  upon  the  face,  arms,  or  body,  but  also 
upon  the  sole  of  the  foot,  especially  in  women,  and  at  times  under 
the  finger  nail,  forming  the  so-called  melanotic  -wliitlows. 

Pathology. — Pathologically,  they  always  spring  from  nevoid 
cells,  and  it  is  still  a  matter  of  dispute  as  to  whether  these  eells 
are  of  epidermal  or  of  mesoblastic  origin;  henee  it  is  fjucstionable 
whether  the  tumors  should  be  called  carcinomata  or  sarcomata. 
Fordj-ce"*  has  recently  reviewed  the  question  very  thoroughly,  and 
the  following  account  is  largely  derived  from  his  excellent  article. 
Following  the  Avork  of  von  Demievillc^  in  1880  and  von  Reckling- 
hausen*^ in  1882,  these  neoplasms  were  regarded  as  endothelial  in 
origin  until  1893,  when  Unna  promulgated  his  now  well-known  views 
that  they  were  of  epiblastic  descent.  Unna  states:  "From  the  fact 
noted  in  describing  ncvi,  that  the  Avcll-known  cellular  cords  of  soft 
nevi  consist  of  true  epidermic  epithelium,  which  has  been  snared  off 
from  the  surface  epithelium  in  the  embryonic  period  or  in  early 
youth,  the  development  of  cancer  in  them  is  quite  comprehensible, 
indeed  self-evident."  Krompecher,"  too,  agrees  Avith  Unna,  stating 
that  the  masses  of  nevoid  eells  can  be  seen  springing  from  the  basal 
layer  of  the  epidermis  in  many  instances;  that,  furthermore,  they 
can  be  demonstrated  to  arise  directly  from  the  basal  cells.  lie  states 
definitely  that  the  prickle  cells  do  not  degenerate  into  nevoid  cells, 
as  Hodara^  says.  Gilchrist  has  shown  the  same  things  as  Krom- 
pecher. 

On  the  other  hand,  many  pathologists  hold  that  the  nevoid  cells, 

*Fordyce:  Jour.  Amer.   Med.  Assn.,  1910,  liv,   91. 

"von  Denieville:  Virchow's  Arch.    f.   Path.   Anat.,   1880.   Ixxxi,   333. 

«von  Recklinghausen:  t'ber  die  Multiplen  Fibrome  der  Haut,    Berlin.   1882. 

'  Krompecher:  Der  Basalzellenkrebs.     . 

*  Hodara:  Monatsh.   f.   prakt.  Dermat.,   1897,   xxv.   205. 


NKVOCARCINOMATA    AND    MAI-.I(;NA.\T    M  KlyANOMATA,  115 

CHpccially  IIk^  clironKitoiiliorcH,  have  lliclr  oiij/in  in  the  mCKfKlorm, 
On  thin  side  ari;  ^■r(»iipc<l  V'iffhow,  Sohhin,'  I'.oi-sl,'"  Kreihifli,  Ril)- 
bert,^^  and  Adaini.'- 

Johnston,^"'  ill  a  ycry  coinplclc  nrtidc,  (Iccidcs  1li;il  tK\i  ;irf!  iiHual- 
ly  of  cndotliolial  ofif^in,  .s[)riiif^iiij4'  from  llio  JyiM[)h  vessels.  Foi'dyee 
holds  that  ncvi  in;iy  Jiavc;  a  twofold  orif^iii.  lie;  stales:  "Jii  some 
the  character  of  th(^  cells  eoiiloi'ins  more  closely  with  thctse  of  the 
epideniiis,  and  can  hardly  be  distiiij^uished  from  the  proloiif^ations 
of  the  latter,  which  enter  the  mole.  Jn  others  thei-e  aj)j)ears  to  be 
another  variety,  consisting  of  cells  Avith  vesicular  nuclei,  with  faint 
or  no  tinctorial  properties  and  a  well-defined  border.  Their  shape 
in  general  is  round,  but  this  ma}^  be  modified  by  mutual  x^i'cssure. 
Fibers  from  the  connective  tissue  may  be  seen  between  individual 
cells  and  groups  of  them." 

As  regards  the  origin  of  the  tumors  propei',  a  number  have  been 
definitely  proven  to  be  of  epithelial  origin,  and  therefore  entitled 
to  the  name  of  carcinomata.  The  cases  reported  by  the  following 
men  are  now  almost  universally  classed  as  of  epithelial  origin: 
Johnston,  Gilchrist,^"*  Waelseh,!^  Whitfield,^^  Darier,"  Schalek,^«  and 
Ravogli.^^  Johnston  comes  to  the  following  conclusions:  (1)  Aside 
from  the  natural  division  into  choroid  and  skin  tumors,  melanotic 
neoplasms,  which,  from  their  diversity  of  origin,  are  best  called  me- 
lanomata,  show  several  varieties.  (2)  The  commonest,  and  there- 
fore the  most  important,  is  that  derived  from  the  soft  nevi,  which 
are  endotheliomata  of  lymph  vessel  origin.  Nevomelanomata,  whose 
histogenesis  it  is  not  possible  to  determine,  must  be  referred  to  the 
same  origin.  (3)  A  second  variety  exists  with  the  same  histologic 
pictures,  which  does  not  spring  from  nevi,  and  whose  origin  is  di- 
rectly traceable  to  endothelium,  probably  also  lymphatic.  This  group 
includes  the  melanotic  whitloAv  and  the  malignant  lentigo  of  the 
French.  (4)  A  third  division  is  truly  epithelial  in  origin,  although 
its  existence  has  been  denied.  These  tumors  are  of  various  tA^pes  and 
show  only  very  slight  tendency  to  malignancy,  a  fact  sufficient  in 


'  Soldan:  Arch.  f.  Klin.  Chir.,  1899,  lix,  261. 
"  Borst:  Die  Lehre  von  den  Geschwlilsten,   1902,  117. 
"Ribbert:  Geschwiilstelehre,   1904.  277. 
^=Adami:  Principles  of  Pathology-,  i,  764. 
"  Johnston:  Jour.  Cutan.  Dis.,  1905,  xxiii,  1. 
"Gilchrist:  Jour.   Cutan.   Dis.,   1899,  xvii,   117. 
^^Waelsch:  Arch.   f.   Dermat.   u.  Syphil.,  1900,  xlix,   249. 
"AVhitfield:  Brit.   Jour.  Dermat.,  1900,  xii,   267. 
'"Darier:  La  Pratique  Dermatologie,  iii,  1903. 
I'Schalek:  Jour.   Cutan.  Dis.,   1900,  xviii,   147. 
"Ravogli:  Jour.   Cutan.  Dis.,   1901,  xix,   1. 


116  SKIX    CANCER. 

itself  to  determine  a  eardial  dift'crence  from  tlu>  melanoendothelio- 
inata.  whose  capacity  in  this  direction  can  hardly  be  exafj:{i:eratcd. 
(5)  A  histolojLijical  diaj^nosis  is  the  only  ]iroper  method  of  dif- 
ferentiation between  the  two.  Adami  says:  "Pifjmented  tumors  of 
a  i>ure  cpitheliomatous  ty]H^  are  unknown/'  but  Fordycc  thinks  that 
he  is  mistaken  in  this. 

To  the  author  the  following  conclusions  seem  irresistible:  (1) 
Nevoid  cells  have  a  twofold  origin,  one  from  the  basal  cells  of  the 
epidermis,  and  another,  not  yet  determined,  po.ssil)ly  from  the  endo- 
tlu'lium.      {'2)      ^lalignaiit    iiu'lanoiuata    of   tlic   skin   spring  directly 


Fig.    49. — Low-power    photomicrograpli    ui     .i     malignant    pigmented    mole     (nevo- 
carcinoma).      (Autlior'.s   collection.) 

from  these  cells.  (3)  Melanotic  sarcomata  may  spring  from  other 
organs,  as  from  the  choroid,  the  gall-bladder  (Duval),-"  adrenal 
(Orth),-^  and  numy  other  organs.  (4)  Lymphangioendotheliomata 
arc  not  nearly  so  malignant  as  these  tumors  (see  chapter  on  endo- 
thelial tumors).  (5)  Basal-celled  carcinomata  are  certainly  not  as 
malignant  as  this  group.  The  whole  question,  then,  is  still  unset- 
tled, although  it  seems  probable  that  some  of  these  luiiiois  are  car- 
cinomata and  some  sarcomata. 

^licro.scopically,   a  fully  developed    tumor    (Figs.    49,    50)    shows 


="  Duval:     Montreal  Medical  Jour.,   1008,  xxxvii,   270. 
"Orth:  Berlin   klin  Wclin.schr.,   lOOfi,   xxvi. 


NI";VOCAI{(MN()MA'rA    AM)    M  AI-KiN  A  N'l'    M  I  :i- \  NO.M  \T  \  . 


117 


cither  ail.  alveolar  ;i,rr;i;iif^'ctiiciil  of  \;w'/c  or  siii;ill  '•dls,  huiidlcs  of 
Hpindlc-  and  oat-Hhaped  cells,  uv  ;i  coinhiii;!!  ion  of  tlic  two,  the  ]>]<:- 
turc  varying  in  different  j)or1ioiis  of  1lic  sjunc  Imnor.  The  amount 
of  chromatin  varies;  in  sonu;  fIrMs  not  only  lln-  ''(jl  nucleus  may 
be  obscured,  but  even  tlie  <'eli  sluipe,  uliile  in  oilier  liclds  it  is  pres- 
ent in  comparatively  small  amounts.  J>orst  has  poinlcd  out  that 
there  was  more  pigment  nenr  the  great  Ijlood  vessels.  The  melanin, 
which  is  the  pigment  present,  is  in  the  form  of  fine  amoi-phous  gran- 
ules, varying  in  color  from  a  golden  yelloAV  to  a  veiy  deep  brown. 
It  is  generally  conceded  1o  be  1lic  (iii;il  st;i.g(!  of  the  cell,  and,  where 


Fig.    50. — High-power    photomicrograph   of   malignant   mole.      (Author's    collection.) 

there  is  most,  the  cell  is  the  oldest  or  the  best  nourished.  As  re- 
gards the  origin  of  the  melanin,  it  is  still  undetermined  whether  it 
arises  from  the  blood,  or  whether  it  orginates  in  the  cutis  or  the 
epidermis. 

Diagnosis. — As  a  general  rule,  the  diagnosis  of  these  tumors  is 
only  too  easy,  for  they  are  rarely  seen  before  metastases  have  oc- 
curred. In  the  author's  experience  two  conditions  have  proven 
troublesome,  which  may  best  be  illustrated  by  case  reports.  In  the 
first  instance  a  young  girl  consulted  him  because  of  a  jet-black  tu- 
mor that  had  developed  upon  the  edge  of  an  old  vaccination  scar. 
Examination  showed  a  tumor  about  the  size  of  a  pea.  firmly  adherent 


118  SKIX   CAXCKK. 

to  the  deeper  layers  of  the  skin,  and  witli  dihUed  lilood  vessels  ex- 
tending from  it.  It  was  completely  excised  with  a  wide  margin, 
and  microscopical  examination  showed  that  there  had  l)een  a  small 
venous  angioma,  into  which  hemori-hage  had  taken  place  .some  time 
before,  and  that  the  blood  pigment  had  remained.  The  other  ease 
was  somewhat  similar.  On  the  edge  of  the  nostril  there  had  de- 
veloped a  ma.ss  that  was  black  in  coloi-.  and  the  diagnosis  of  melanoma 
was  made.  Histological  examination,  as  well  as  the  later  course  of 
the  disease,  showed  that  the  growth  was  inflammatory  tissue  into 
which  hemorrhage  had  taken  place  with  the  deposit  of  blood  pig- 
ment. Histologically,  this  case  was  very  difficult  to  distinguish  from 
&  true  melanotic  tumor,  and  was  watched  with  a  certain  amount  of 
suspicion  for  some  montlis. 

ProgTiGsis. — Tlie  prognosis  is  bad.  Bloodgood--  states  that  he 
lias  tht'  ]\'eord  of  but  one  case  that  has  survived — a  case  of  Dr.  Wain- 
"wright,  of  Scranton,  who  is  alive  seventeen  years  aftei-  operation. 
The  histological  picture  was  such  that  the  true  melanotic  nature  of 
the  tumor  could  not  be  doubted.  Pringle-'  has  reported  two  cures, 
which  Bloodgood-*  does  not  accept.  As  a  general  rule,  patients  die 
inside  of  two  years,  but  in  a  few  instances  life  is  prolonged  well 
beyond  that  time.  It  is  possible  that  in  some  few  instances  life 
might  be  saved  by  a  very  extensive  early  oiieration.  an  operation  in- 
cluding the  glands. 

Treatment. — Pi-evention  is  much  better  than  cure.  Every  ac- 
quired mole  should  be  removed,  preferably  with  either  the  knife  or 
actual  cautery,  so  as  not  to  irritate  the  nests  of  nevoid  cells.  Every 
congenital  mole  that  is  subjected  to  irritation  should  be  removed. 
Whenever  a  mole  begins  to  gi'ow,  or  to  show  any  evidences  of  either 
irritation  or  ulceration,  it  is  an  imperative  sign  for  immediate  oper- 
ative interference,  although  this  will  often  be  too  late.  When  skin 
or  internal  metastases  have  numifested  themselves,  treatment  is  use- 
less; neither  Coley's  serum,  x-ray,  nor  radium  Avill  have  the  slightest 
influence.  In  the  cases  where  the  involvement  is  glandular  only, 
either  extensive  block  dissection  of  the  glandulai-  vessels  and  glands, 
or.  if  the  growth  be  upon  a  limb,  aini)utation  might  cure. 


==  Bloodgood:  Progressive  Medicine.  Dec,  l!tl2. 
"  Pringle:  Edinburgh  Med.  Jour.,  June,  1008. 
='  Bloodgood:  Progressive  Med.,   Dec.,   1909. 


CIIAPTEU  X. 

CARCINOMA  EN  CUIRASSE— CARCINOMA  BY  EXTENSION— 
METASTATIC^   CARCINOMA— FACET'S    DISIOASH. 

CARCINOMA  EN  CUIRASSE. 

Pollitzer^  has  recently  written  an  excellent  article  on  carcinoma 
of  this  type,  and  the  author  has  drawn  freely  from  it. 

Just  as  in  many  other  cancerous  conditions,  there  are  many  de- 
grees of  involvement,  and  the  author  can  see  no  reason  for  not  call- 
ing even  minor  involvement  of  the  lymphatics  of  the  skin,  causing 
induration,  by  the  name  of  cancer'  en  cuirasse,  although  many  will 
not  accept  this  view. 

Clinical  Course. — This  type  of  cancer  Avas  first  described  by  Vel- 
peau  about  seventy-five  years  ago,  and  fully  developed  instances  are 
very  rare.  The  trouble  probably  always  begins  in  the  glands  of  the 
breast,  notwithstanding  the  statements  of  Rodman  and  Besnier  to 
the  contrary.  In  a  typical  case  Ave  find  a  breast  cancer,  with  re- 
traction of  the  nipple,  and  possibly  all  of  the  other  signs  of  a  typical 
mammary  carcinoma,  although  the  skin  of  the  gland  may  be  so  in- 
durated that  it  is  impossible  to  palpate  the  primary  tumor.  Begin- 
ning in  the  breast,  and  extending  from  it  over  the  chest  and  back, 
to  a  greater  or  less  extent  the  skin  is  reddened,  very  hard  and  firm 
to  the  touch  and  feeling  like  a  sclerodermatous  cutis  (Fig.  51). 
There  may  or  may  not  be  very  numerous  small  angular  or  round 
papules  present,  but  there  are  usually  a  few.  These  papules  may 
resemble  the  lesions  of  lichen  planus  to  a  marked  extent.  Pollitzer 
says  that  in  his  case  the  appearance  Avas  that  of  a  lichen  planus 
developing  upon  a  sclerodermatous  area.  The  glands  may  or  may 
not  be  involved,  and  the  disease  usually  runs  a  comparatiA-ely  sIoav 
course,  about  that  of  a  slow-growing  scirrhous  carcinoma.  OAviug  to 
the  obstruction  of  the  lymphatics,  the  arm  may  become  markedly 
edematous.  At  times  there  is  A-ery  intense  itching  over  the  diseased 
area,  and  movement  is  usually  greatly  limited  and  at  times  painful. 

Pathology.— The  pathology  of  the  condition  is  comparatively  sim- 
ple. Instead  of  passing  through  the  lymph  vessels,  the  cancer  cells 
have  groAA-n  into  them  in  long,  finger-like  projections,  almost  com- 


1  Pollitzer:  Jour.   Cutan.  Dis.,  1909.  xxvii.  143. 

119 


no 


SKIN    CANCER. 


pletcly  filling  the  luiuens.  Very  little  of  the  eaneeroiis  tissue  is 
found  outside  of  the  lynii)haties.  There  is  very  little  inilanunntory 
reaction  in  the  cutis;  the  blood  vessels.   p:l!^»ds  and  connective  tis- 


/ 


.<  »-..!?r\3 


Fig.    51. — Carcii  oiiia    on    cuira.- 


(Suttoii'.'^   coUfotion.) 


sue  are  unehaufjed.  The  lichenoid  papules  are  due  to  a  hypcracan- 
thosis  over  three  or  four  of  the  papilla*,  and  not  to  the  deposit  of 
cancerous  cells  in  the  more  superficial  portions  of  the  skin.  The 
erythema  is  probably  due  to  the  effect  of  the  toxins  upon  the  vaso- 
motors in  a  region  in  which  the  flow  of  lymph  is  obstructed.     Cer- 


(jAii(MN()MA  in'  i;x'ri;.\si()X. 


121 


tain  of  the  nodules  lluii  <';iii  (H'c;isi(iii;ill\  !)'•  fdf  (lcc[icr  in  Iho  skiji 
arc  duo  to  accuinuhillons  ;iimI  i^i'owIIi  of  cimicci'  fdls  llinl,  havo  ch- 
capcd  from  tli(!  I,yiii|)li;i1  ics  ;iiiil  st;ir1<i|  1u  ^row  in  llio  fomiffl  i\f 
tissue. 

Diagnosis. — The,  di;ii;iiosis  nmsl  he  mndc  IVom  erysipehis,  sclo- 
rodci'iua,  and  lichen  ])l;iiuis,  jukI  sIioiiM  he  e;isy,  pro\ide(l  ihat  a 
careful  examination  is  mnde.  l^^spccially  should  tlif;  nifif)les  be  ex- 
amined for  retraction,  ;ind  tiio  lesions  carefully  [);dpated. 

Treatment. — "When  this  stajje  of  cancci-  li;is  been  i-eaehed,  lho 
treatment  eonsisis  simply  in  keeping'  1]ic  p;i1i(Mi1  ;is  eonifoitnljle  as 
possible. 

CARCINOMA  BY  EXTENSION. 

Clinical  Course. — Now  that  llic  public  is  bcKinuinjj;'  to  more  fully 
appi'cciatc  the  danger  of  lumps  or  tumors  in  any  part  of  the  body, 


Fig.    52. — Extension   of   carcinoma   of    the   breast.      (Author's    collection.) 


the  surgeon  does  not  often  see  a  case  with  ulceration  through  the 
skin,  except  after  an  unsuccessful  operation.  Fungating  tumors  of 
the  skin  are  probably  commoner  after  cancer  of  the  breast  than  after 
any  other  type  of  cancer  (Fig.  52).  although  it  is  not  unusual  for 
lymph  glands,  infected  with  cancerous  material,  to  break  down  and 


122  SKIN  CANCER. 

form  deep  ulcers.  Two  clinical  tyjies  of  cancer  by  extension  are 
seen — the  funy:ating  and  the  nlccratin},'.  In  the  former  a  mass  of 
papillon\atous  tissue  extends  through  the  skin.  The  color  is  some- 
what that  of  dirty-looking  granulation  tissue,  but  always  covered 
with  a  necrotic  menibrano.  There  is  usually  considerable  discharge 
and  the  odor  is  very  foul.  In  tiie  ulcerating  variety  there  is  an  ul- 
cer of  more  or  less  dvpth.  willi  a  liard  edszT,  dirty  liaso,  and  a  find 
discharge. 

Pathology. — The  i)ath<il()gy,  of  course,  depends  entirely  on  the 
variety  nl"  antecedent  tumor. 

Treatment. — These  conditions  may  at  times  be  temporarily 
ameliorated  by  operation,  but  the  chances  for  a  i>ermanent  cure  are 
very  slim,  although  x-ray  treatment  has  appaixiit!\-  rtiictl  a  few, 
and  radium  promises  something. 

METASTATIC  CARCINOMATA. 

Clinical  Course. ^It  is  rare  to  iiud  cancer  of  any  of  the  organs 
metastasizing  to  the  .skin,  but  this  does  occasionally  happen.  Kauf- 
mann-Wolf-  has  recently  Avrittcn  a  very  complete  article  on  the  sub- 
ject, and  has  collected  all  of  the  pul)lished  eases,  sixty-fi\e  in  num- 
ber. It  is  to  this  article  that  the  author  owes  tlie  following  state- 
ments. 

The  condition  is  very  rare.  Rieclielniann.''  in  autopsies  upon  711 
carcinomatous  subjects,  did  not  once  encounter  this  condition,  Buday* 
found  it  three  times  in  366  cases,  while  Krasting'  mentions  .seven  in- 
stances of  cutaneous  metastases  in  1,078  carcinoma  cases,  four  of 
these,  however,  being  associated  with  mammary  cancer. 

Out  of  the  sixty-five  cases  that  Kaufnumn-AVolf  has  collected, 
twenty-three  followed  cancer  of  the  stomach ;  three  cancer  of  the 
liver;  two,  cancer  of  the  pancreas;  ten,  cancer  of  the  uterus;  one, 
cancer  of  the  ovary;  six,  cancer  of  the  lung;  two,  cancer  of  the 
mediastinum;  two,  cancer  of  the  esophagus,  w^hile  the  remainder 
sprang  from  various  other  organs.  Twenty-three  of  the  patients 
were  men;  thirty-three  were  women,  while  in  the  other  instances  the 
sex  was  not  stated.  Many  of  the  patients  were  extremely  old,  but 
some  were  comparatively  young,  so  it  is  improba])lc  that  age  is  a 
factor. 

In  onlv  one  or  two  instances  was  there  a  .solitary  metastasis  to  the 


=  Kaufmann-Wolf :  Arch.   f.   Dermat.   u.   Syphil..    1013,    cxiv,   709. 
'  Riechelmann:  Berl.  klin.  AVchn.schr.,  1902,  728,  758. 
*  Buday:  Zeitschr.   f.   Kreb.';for.schung,  vi,   26. 
"Krasting:  Zeitschr.  f.   Krebsforschung.   iv.   3.36. 


1'Agi:t'w  diskas'k.  123 

skin;  in  the  majority  of  instaiiwK  tlif  coiKlilioii  was  sirni)ly  asHOoi- 
ated  with  a  general  carcinoinatoHis.  In  IIk;  skin  there  are  tlirce  forms 
of  tumors — solitary  nodules,  y'l-oups  of  nodnlfs,  ;inr|  ;i  fl;if.  infiltra- 
ing  form  of  neoplasm.  Tlu;  tumors  are  i-ather  pi-one  to  early  ul- 
ceration, except  in  tliose  cases  where  the  })atholot,'y  shfjwed  Ihe  eon- 
dition  to  be  one  of  lymphatic  infarction. 

In  some  of  the  instances  the  ]);itirii1  died  very  sooji  jif'lcr  the  ap- 
pearance of  the  cutaneous  manifesiaiiu)is,  but  the  averaj,fe  dui-ation 
of  life  after  cutaneous  metastases  had  taken  place  was  about  six 
months.     One  patient  lived  for  one  and  a  half  years. 

As  accompaniments  or  prodromal  symptoms  there  were  found 
edema,  herpes  zoster-like  vesicles,  erysipeloid  erythema,  lichenoid 
conditions,  and  urticarial  phenomena.  With  lymphatic  infarction  the 
edema  was  rather  constant.     Itchinj^  was  often  complained  of. 

Pathology. — The  type  of  cancer  found  in  the  skin  depends  on 
the  nature  of  the  primaiy  growth. 

Treatment. — Treatment  consists  in  keeping  the  patient  comfort- 
able. 

PAGET 'S  DISEASE. 

This  condition  was  first  described  by  Paget'^'  in  1874,  and  since 
that  time  has  been  the  subject  of  much  study.  Especially  has  it  been 
debated  whether  the  cutaneous  changes  antedated  or  followed  the 
development  of  a  cancerous  change,  and  even  yet  this  question  is 
not  absolutely  settled. 

Clinical  Course. — Paget 's  disease  usually  begins  as  a  peculiar 
raw,  granulating,  weeping  eczematous  patch  around  the  nipple  of 
a  woman  past  middle  life.  Later  the  breast  is  noted  to  be  the  seat 
of  cancer,  and  there  is  the  same  fatal  termination  so  common  in 
other  instances  of  this  malady. 

The  disease  is,  however,  subject  to  many  variations.  In  some  in- 
stances, from  a  clinical  standpoint,  the  cutaneous  lesion  is,  very 
clearly,  simply  an  example  of  a  chronic,  weeping  eczema.  In  other 
instances  the  cancerous  change  undoubtedly  antedates  the  skin 
changes.  Hartzell"  has  collected  nineteen  illustrations  of  the  occur- 
rence of  Paget 's  disease  on  other  portions  of  the  body  than  the 
breast.  These  extramammary  cases  are  most  common  upon  the  penis, 
but,  as  Hartzell  well  shows,  may  develop  upon  almost  any  other 
portion  of  the  body.  In  the  discussion  of  Hartzell 's  paper  it  was 
generally  agreed  that  it  is  not  at  all  unusual  to  find  these  extra- 


«  Paget:  St.  Bartholemew's  Hosp.  Rep.,  1874.  v,  87. 
■Hartzell:  Jour.   Cutan.   Dis..   1910,   xxviii,   379. 


rj4 


8K1X    I'ANCr.R. 


manunary  eases,  and  nearly  every  cleriuatolotrisl   of  wide  ex])erienee 
has  seen  one  or  more. 

In  the  breast  cases  the  dermatitis  may  exist  for  as  nuu-h  as  eijjht 
or  ten  years  before  the  cancer  is  clinically  demonstrable,  and.  inas- 
mnch  as  cancer  of  the  breast,  when  nntreated.  almost  invariably 
runs  a  nu»re  rapid  course  than  that,  it  is  ])r()baltlc  that  the  der- 
matitis is  the  original  lesion,  and  is  not  secondary  to  the  neoplasm, 
as  Jacobeus"'  ami  others  believe.  The  cancer  does  not,  by  any  man- 
ner of  means,  always  develop  directly  from  the  diseased  skin,  al- 
though it  not   infrecjucntly  does  so.  l)ut   in  many  instances  it  arises 


Fig.    53. — Hi-stology   of   Paget's   di.sease.      (Author'.s    collection.) 


at  a  distant  point,  and  from  the  glandular  ci)ithclium  and  not  from 
the  cutaneous  cells.  In  the  extramammary  cases  the  cancer  develops 
from  the  skin  cells,  and  usually  in  from  two  to  three  years  after 
the  dermatitis  has  manifested  itself.  It  then  runs  the  course  of  the 
more  malignant  prickle-celled  neoplasms,  not  forming  the  typical 
rodent  ulcers. 

Pathology. — Pathologically,  the  condition  is  extremely  interest- 
ing, owing  to  the  presence  of  the  curious  Paget's  cells,  about  which 
there  has  been  much  discussion  (Fig.  53).  It  has  been  thought  by 
some  that  they  were  simply  modified  epithelial   cells,  by  Jacobeus 


^Jacobeu.":  Arch.  f.  path.  Anat.    (Virchow's),  cLxxviii. 


l'A(ii:'l''s    DISICASK.  125 

and  others  tliut  they  wei'e  i)i  i'(!;ility  eaiieer  ccWh  ^rowinf^  iif)  lowjuvl 
the  skin  from  a  decip-seated  eareinoiiia,,  atnl  hy  I);u-icr,''  Wickfiam,'" 
and  othei'S  to  \h'.  |»;ii';isilcs,  llie  soc;illc(|  |»s(»ios[)(riii.s.  I'ractJcally 
all  patholo^'ists  have  now  eoiicech'd  1li;il,  IIk;  (ii'st  view  was  eorreet, 
and  tluit  tliey  are  simply  modilied  and  (Jej^enerated  j)i'if',kle  eells,  dc- 
riv(Ml   from   tiu!   epidcnnis. 

Tli(5  inti'apapillaiw  processes  are  much  loiif^er  1lian  nsiial,  and  are 
rounded  rather  than  ])oiiited.  The  cells  are  often  widely  sepai-atcd, 
due  to  the  presence  of  intraeellnlar  edema,  and  have  lost  their 
l)ricklcs.  Some  of  the  cells  are  as  much  as  30  microns  in  diameter, 
and  usually  contain  a  very  large  nucleus,  lying  in  a  vesicle.  Other 
cells  show  similar,  but  not  so  marked,  changes,  which  have  been 
very  well  described  by  Unna.^^  There  is  a  very  considerable  cellu- 
lar infiltration,  both  of  the  rete  and  the  adjacent  portion  of  the  cor- 
ium.  These  changes  are  true,  not  only  of  the  typical  breast  changes, 
but  of  the  cutaneous  cases  as  well. 

Should  the  disease  be  regarded  as  a  true  pi-ecancerous  condition, 
or  as  a  disease  sui  generis,  as  maintained  by  Unna?  In  the  extra- 
mammary  cases  it  is  probably  an  example  of  a  true  precancerous 
dermatosis,  but,  inasmuch  as  in  the  breast  cases  the  cancer  may  de- 
velop at  a  distant  site,  it  can  hardly  be  assumed  as  a  pathological 
precancerous  change,  but  simply  as  a  clinical  entity  that  definitely 
warns  that  a  deep  cancer  may  follow.  As  a  general  rule,  precan- 
cerous changes  are  dry  and  hard,  and  not  moist  and  weeping  as  in 
Paget 's  disease. 

Prophylaxis  and.  Treatment. — At  any  rate,  there  is  one  very  im- 
])ortant  lesson  to  be  learned,  a  lesson  that  has  as  yet  not  been  suffi- 
ciently emphasized.  Any  patient  with  an  intractable  eczema  of  the 
nipple  region  should  invariably  have  a  biopsy  performed,  and.  if 
the  sections  show  the  changes  characteristic  of  Paget 's  disease,  that 
breast  should  be  removed  without  any  delay,  for  it  will  inevitably 
become  cancerous.  AVhether  the  glands  should  be  removed  depends 
probably  on  the  stage  at  which  the  operation  is  performed.  If  there 
is  the  slightest  clinical  evidence  of  cancer,  a  complete  operation  must 
be  done,  but,  if  clinical  examination  and  the  careful  examination  of 
the  breast  when  it  has  been  excised  show  no  naked  eye  appearances 
of  cancer,  then  the  simple  removal  of  the  breast  will  suffice.  How- 
ever in  all  instances  a  microscopical  examination  of  the  removed 
tissue  should  be  made. 

The  cutaneous  cases  should  be  treated  in  the  same  way.     If  they 


»  Darier:  Soc.   de  Biologie,  April  13.  ISSn. 

^"Wickham:  iSIaladie  de  la  peaii  dite  maladie  de  Paget.  Paris,   1890. 
"Unna:  Histopathology  of  the  Diseases  of  the   Skin. 


12G  SKIN    CANCKK. 

are  examples  of  extrainaniinary  Pa-rt't 's.  Iliey  sluuilil  lie  cxcisotl  with 
a  fjoodly  margin. 

Onec  caneer  has  develoiieil.  the  prognosis  is  ii;ituiall.\  unfavorable. 
as  only  a  very  extensive  oi>oi'ation  Wdiild  ^ivc  tlu'  paliciit  a  (light- 
ing ehanee  for  life. 


CIIAPTKR  XT. 
ENDOTIIELIOMATA. 

Anionjjs'  patholo^isls  tliccc  is  slill  miicli  cont'iisioii  \-f<^;wi\\u<^  llif; 
status  of  endotheliomas,  and  what  Iiiiihus  sImhiM  he  called  by  this 
name.  In  a  recent  ai-ticle  Fick^  contends  that  the  patholof^ical  en- 
tity known  as  endothelioma  never  has  and  never  can  exist,  and  that 
the  so-called  endothelial  cells  are  in  reality  cpiHiclijil  in  oi-ij^in,  ]>er- 
haps  derived  from  some  of  the  fi^landnlar  (sleinents.  On  the  other 
hand,  Zeit,-  in  an  excellent  article,  maintains  that  many  of  the  so- 
called  alveolar  sarcomata  and  carcinomata  arc  undoubtedly  examples 
of  endotheliomata.  This  confusion  is  undoubtedly  due  to  the  vari- 
ability of  the  cells.  Zeit  remarks:  ''Morphologically,  an  endotheli- 
oma may  resemble  typical  (adenoma)  or  atypical  (carcinoma)  or- 
ganoid structures,  or  t3^pical  (fibroma)  or  atypical  (sarcoma)  histoid 
growths.  It  is  extremely  confusing  for  the  student  who  has  learned 
how  to  diagnose  common  atypical  histoid  growths,  as  sarcomata  and 
atypical  organoid  tumors  as  carcinomata  or  endotheliomata,  to  read 
of  the  diagnosis  of  an  at^^pical  organoid  tumor  by  Billroth  as  alveo- 
lar sarcoma;  by  Rindfleisch  as  sarcoma  endotheliale ;  by  AValdeyer 
and  Kolaczek  as  angiosarcoma ;  by  Fischer  and  Cramer  as  endothelial 
sarcoma."  And  the  author  much  fears  that  it  is  not  alone  the  stu- 
dent who  is  confused,  but  even  some  of  these  A-ery  writers  them- 
selves. 

Zeit  goes  on  to  say  that  a  correct  clinical  diagnosis  is  of  the  great- 
est importance  to  the  surgeon  because  endothelial  tumors  grow  very 
much  more  slowdy  than  sarcomata,  and  do  not  produce  metastases 
until  they  have  existed  for  some  years.  At  the  same  time,  they  are 
very  prone  to  recur  after  operative  removal. 

The  following  scheme  of  classification  is  usually  adopted: 

1.  Lymphangioendothelioma. 

2.  Hemangioendothelioma. 

3.  Perithelioma. 

The  perithelial  tumors  originate  from  the  endothelium  lining  the 
perivascular  lymph  spaces,  and  hence  there  is  some  discussion  as  to 


iFick:  Dermat.  Wchnschr.,   1012,   liv,   4SS. 

=  Zeit:  Jour.  Amer.   Med.   Assn.,   1P06,   xlvi,   £67. 

127 


128  SKIN    CANri'.R. 

wlu'ther  thoy  should  be  calkHl  lK'iuaiijj:ii)eiulothelioiiias  or  lymjilian- 
}j:iiH'iuk)tholit)iniis.  ai'i'ordin«r  tn  some  authors.-'  On  the  other  hand, 
Zcit  ein]>hatieally  says:  "The  ])ei'ithelial  inemln-aiie  nuist  be  dif- 
ferentiated from  tlie  jierivaseuhir  lyniidi  spaees  of  His,  whieh  he 
found  surroundin<r  the  adventitia  of  arteries,  veins,  and  eapilhiries  of 
the  central  ner\-ous  system.  The  perithelium  is  the  outer  lininj;  of 
the  adventitia  of  blood  ves.sels.  outside  of  Avhieh  is  tlie  i)erivaseular 
lymph  space."  Zeit  further  states  that  the  true  pcrithcliomata  arc 
the  tumors  arising  from  the  perithelium  and  not  from  the  lymph 
space,  and  henee  sliould  he  caHod  In  miDKixx  ndolhclioma  pcrivascu- 
larr. 

At  any  rate,  up  to  the  i)resent  time,  there  is  in  the  literature  but 
one  definite  case  report  of  a  jierithelioma  of  the  skin,  and  that  is  a 
case  reported  by  Brandeis  and  Pouget,'*  where  there  -were  a  number 
of  metastases  from  a  tumor  of  the  adrenals. 

From  carcinomas  the  histoloj?ical  diagnosis  can  be  made  from 
carefully  noting  the  following  differences,  according  to  Zeit: 

1.  "The  tumor  cells  in  endothelioma  arc  intimately  connected 
with  the  stroma,  and  cannot  be  l)rushed  out  of  the  stroma,  as  in  the 
case  of  carcinoma,  in  which  the  epitlu'Iial  cells  may  also  retract 
from  the  stronui  and  show  s]>aces. 

2.  "Endothelial  cells  produce  inti'accllular  cement  substance  and 
are  closely  packed  together,  whereas  the  epithelial  cells  in  carcinoma 
have  no  intercellular  substance  and  form  no  compact  layers. 

3.  "In  endothelioma  delicate  fibrillar  processes  extend  from  the 
walls  of  the  alveoli  into  the  proliferated  cell  masses.  They  are  ab- 
sent in  carcinoma. 

4.  "In  endothelioma  the  cell  masses  consi.st  of  a  dense  mosaic 
of  many  layers  of  cells,  witk  small  skarply-outlined  nuclei,  sur- 
rounded by  a  broad  envelope  of  clear,  glassy  perinuclear  protoplasm. 
Carcinoma  cells  have  large  vesicular  nuclei,  witk  a  moderate  amount 
of  perinuclear  ])rotoplasm,  more  or  less  granular. 

5.  "In  endothelial  tumors  the  cells  are  arranged  in  the  form  of 
cellular  cords  and  cylinders  (round  masses  in  carcinoma),  and  may 
separate  out  hyaline  material  (cylindroma)  or  form  lumina-likc 
masses  (sieve-like)  in  the  cellular  cords,  due  to  secretory  processes 
of  endotkelial  cells. 

6.  "To  distinguisk  tkc  endothelial  tumors  from  sarcomata,  it  is 
to  be  remembei'cd  that  the  former  have  an  organoid,  the  latter  a  hi.s- 


*Adami:  Principles  of  PathDlog.v.    i.   758. 

*  Bramlei.s  and  Pouget:  Ann.  de  Derniat.  ct  de  Syphil.,  1910,  5th  .ser.,  i,  506. 


KNDO'I'HIJJOMA'I'A.  129 

toid,  structure.  Accordinf^  U)  lliis  <\ci\\\\\'\<m,  every  lar^c-cc]]  nar- 
coma  with  a  wcU-dovclopcd  Htroina,  ulii^-li  \'.;is  fot-niorly  called  alveo- 
lar sarcoma,  would  ])C  called  an  endolliclioin;!. " 

As  Ilertzler"'  well  poinls  (uil,  liowcNcr,  llifi-f  may  bo  so  many 
changes  associated  with  an  ciidotheliomji  that  it  is  next  to  impos- 
sible for  any  one  excej)t  a  yavy  highly  ti-iiiicd  pjithoiogist  to  correctly 
diagnose  it.  There  may  occur  ;i  hypertrophy  of  both  the  number 
and  size  of  the  vessels  involved,  be  they  lymph  or  blood  channels, 
or  in  other  instances  there  may  occur  a  great  increase  in  the  amount 
of  fibrous  tissue  present  between  the  cells.  The  cells  may  undergo 
marked  degeneration,  so  as  to  almost  resemble  cancer  pearls,  except 
that  the  keratin  is  lacking.  The  vessels  m;iy  nv  m;iy  not  retain  an 
open  lumen. 

Endotheliomas  of  the  skin  are  very  rare  tumors,  and  such  text- 
books as  Crocker,  Hyde,  Stelwagon,  Pusey,  and  even  Mracek's  ex- 
tensive liandhucli  either  make  no  mention  of  the  condition,  or  else 
refer  only  to  the  so-called  endothelioma  capitis. 

In  1907^  Gottheil  reviewed  the  literature,  in  addition  to  report- 
ing a  case  of  his  own.  He  calls  attention  to  the  fact  that  the  le- 
sions have  varied  greatly  in  clinical  characteristics,  and  that  as  yet 
we  have  no  definite  criteria  by  Avhich  they  can  be  diagnosed  with 
certainty. 

Most  of  the  lesions  have  appeared  upon  the  scalp,  either  as  single 
or  as  multiple  tumors.  In  Braun's'  case  there  was  a  solitary  lesion 
that  closely  resembled  a  rodent  ulcer,  especially  as  the  edge  was 
markedly  indurated.  In  the  case  reported  by  Allen®  there  was  a 
single  cartilaginous  lesion,  while  in  Hartzell's^  case  the  neoplasm  was 
softer  and  of  a  yellowish  color.  Von  AValdheim^"  recorded  an  in- 
stance where  there  Avere  multiple,  flat,  smooth  tumors  covered  by  un- 
altered epidermis.  In  the  patient  reported  by  CTOttheil  there  was  a 
solitary,  deeply  pigmented  tumor,  occurring  upon  the  sole  of  the 
foot,  and  closely  simulating  a  melanoma,  except  that  the  groA^iih  had 
been  comparatively  slow.  It  recurred  about  six  months  after  re- 
moval by  the  knife.  In  the  discussion  on  this  case.  Bulkley  recorded 
a  similar  case  upon  the  foot,  which  likewise  reeui-red  after  opera- 
tive removal,  but  which  was  finally  cui'ed  by  the  x-rays.  Dr.  Cocks  re- 
ferred to  a  case  which  Avas  clinicallv  diagnosed  as  moUuscum  fibrosum. 


=  Hertzler:  Treatise  on  Tumors. 

"=  Gottheil:  Jour.  Amei".   Med.  Assn.,  1907,   xlviii,   93. 
■Braun:  Monats.   f.   prakt.   Dermat.,   1893,  xvii,   585. 
s  Allen:  Monats.  f.  prakt.  Dermat.,  1900,  xxxi,   47. 
'  Hartzell:  Brit.   Jour.  Dermat.,   Oct.,   1904. 
^"  von  AValdheim:  Arch.  f.  Dermat.  u.  Syphil.,  1902.  Ix,  215. 


130  SKIN    CANCKR. 

The  author  -has  recently  liad  a  very  interestiii«r  ease  under  his 
own  care.  The  patient  was  a  maiden  lady,  aged  50,  who  had  a  small 
blood-red,  somewhat  friable,  growth  situated  back  of  her  right  ear, 
where  the  spectacles  had  irritated  it.  The  growth  was  about  8  mm. 
in  diameter,-  was  distinctly  pedunculated,  and  there  was  no  indura- 
tion around  the  edge.  It  had  been  present  about  two  months.  On 
account  of  the  rapid  growth,  the  condition  was  diagnosed  as  a  sar- 
coma, and  was  completely  excised  under  local  anesthesia,  and  the 
wound  cauterized  with  acid  nitrate  of  mercury.  Five  x-vay  ex- 
posures were  tlien  given.     There  has  been  no  recurreiife  in  two  years. 


.^.vi-^'P?^ 


^\ 


Fig.    54. — Histology   of   lymphangioLiiduLliLliuina.      (Author's    collection.) 


The  growth  was  diagnosed  microscopically  as  lymphangioendotheli- 
oma by  Dr.  "Welch,  of  Johns  Hopkins  (Fig.  54). 

The  proper  treatment  is  broad  local  excision,  pi-obably  accompanied 
by  cauterization,  for  the  growths  undoul)tedly  have  a  marked  ten- 
dency to  return  at  the  site  of  the  operation,  although  apparently 
they  do  not  form  metastases. 

It  must  be  especially  noted  that  these  growths  have  nothing  what- 
ever to  do  with  the  multiple,  benign,  cystic  growths,  properly  called 
syringocystadenoma.  Many  authors  insist  that  the  latter  are  of  en- 
dothelial origin,  and  wilhiii  a   short  time  Saalfeld'^  has  attempted 


"  Saalfeld:' Technical   Supplement  Urol,   and  Cutan.   Review,   1913,   i,   166. 


NKVO-XAXTIIO-7;NI)f)'l'lli:M().\TATA,  131 

to  describe  two  vjii-iclics,  oik;  Hpringinf:?  I'lom  lln'  lymphatic  crulo- 
thelium,  and  one  from  Uk;  (iiidothclium  of  1lic  hlooi]  vessels.  A  care- 
ful reading  of  his  ai'liclc,  liowovcr,  must,  foii\iiice  one  that  the  orif^in 
was  really  in  the  (^pitlu'liiim  of  tlic  s\vc;it  ducts,  as  in  the  case  so 
well  <l(^sc]'il)('(l  by  Su11oii^'-'  iiiid   ('oii(iniic(l   l»y   Wclfh. 

NEVO-XANTHO-ENDOTHELIOMATA. 

McDonagh^'  has  described  several  cases  of  small  multiple,  yellow 
tumors,  present  at  birth,  which  were  apparently  distinct  from  xan- 
thomata  in  that  the  histological  examination  showed  that  the  cells 
were  probably  of  endothelial  origin.  These  neoplasms  ran  a  totally 
benign  course.     They  tend  to  disappear  spontaneously. 


1=  Sutton:  Jour.  Amer.   Med.  Assn.,   1912,  Iviii,   333. 
"McDonagh:  Biit.   Jour.  Dermat.,  1912,  xxiv,  85. 


CIIAPTKR   XII. 
BEXIGX  COXXECTIVE  TISSUE  TUMORS. 

Before  dealing  ^vitll  the  saiH'omata.  it  seems  ^vise  to  say  u  few 
words  concerning  the  benign  eonneetive  tissue  tumors,  the  sarcomata 
being  the  malignant  connective  tissue  tumors. 

CICATRIX. 

A  cicatrix,  or  scar,  is  a  new  formation  of  connective  tissue,  re- 
placing a  loss  of  tissue  substance.  The  amount  of  scar  formation 
depends,  of  course,  on  the  preceding  loss  of  tissue.  As  a  rule,  a 
scar  contracts  in  the  course  of  time,  although  hypertrophic  scars  may 
form.  At  first  the  color  is  bright-red,  then  dull-pink,  then  white, 
the  color  depending  on  the  vascular  supply.  The  pathology  of  the 
condition  is  admirably  described  in  Adami's  little  book,  "Inflamma- 
tion."^ As  already  pointed  out  in  the  chapter  on  spino-celled  can- 
cer, cicatrices  may  lead  to  the  later  development  of  prickle-celled 
cancer,  but  sarcomas  may  also  develop  in  them. 

KELOID. 

A  keloid  is  a  fibrous  new  growth  tliat,  to  all  intents  and  purposes, 
is  simply  a  hypertrophic  scar.  They  are  not  especially  common  in 
whites,  but  are  very  frequently  encountered  in  the  negro.  In  former 
years  it  was  believed  that  there  were  two  varieties  of  keloid — the 
false,  which  arose  as  the  result  of  trauma,  and  the  true,  which  origi- 
nated in  a  healthy  skin.  It  is  now  generally  conceded,  however, 
that  all  keloids  are  the  result  of  some  injury,  although  it  is  by  no 
means  understood  why  the  overgro^Hh  of  fibrous  tissue  should  oc- 
cur. Keloids  may  be  single  or  multiple,  and  they  may  be  very  small 
or  they  may  reach  the  diameter  of  6  or  even  more  inches.  They 
may  be  either  sessile  or  pedunculated.  The  growth  is  very  hard 
and  firm,  and  usually  distinctly  rounded,  in  addition  to  being  def- 
initely encapsulated.     Keloids  arc  devoid  of  hair. 

Pathologically,  the  condition  has  been  most  carefully  studied  by 
Heidingsfeld,-  Avho  found  that  all  hypertrophic  scars  and  keloids 
were  of  similar  structure,  and  composed  of  dense  bands  of  fibrous 


'Adami:   "Inflammation."  Xew  York,  1907. 
-Heidingsfeld:  Jour.    Amer.    Med.    Assn.,    1909,    liii.    127 

132 


BENIGN    CONNECTIVK   TISSUE    TUMORS.  133 

tissue,  usually  iiniiiin^'  pjii-illcl  uilli  tlu;  siii-fjif-c.  The  opidcj-rnis  is 
usually  njitt('ii(!(l  and  tliiuiiod.  (jilands,  hair  folliflf-s,  and  muscles 
arc  pushed  aside,  and  may  be  somewhat  airofjhied.  There  ai'C  but 
few  blood  vessels  present.  Ah  a  ^'eneral  riih^,  keloids  do  not  become 
inaliji^iiant,  althonj^h  Anderson''  has  re[)orled  a  ease  Avherc  sueh  chanj^e 
did  occur.  The  best  treatment  for  keloids  is  the  x-ray;  in  fact,  it 
is  the  only  treatment  that  is  at  all  satisfactory. 

The  acne  keloid,  or  dermatitis  papillaris  ca7)i]litii,  is  a  collection 
of  small  keloidal  growths  upon  the  back  of  the  neck  and  upon  the 
adjoining  posterior  portion  of  the  scalp.  Each  papule  is  pierced 
by  one  or  several  hairs,  and  there  is  often  pus  in  the  follicles.  The 
condition  has  recently  been  carefully  studied  by  Adam  son.*  X-ray 
is  the  treatment  of  preference. 

FIBROMA. 

True  fibromas  of  the  skin  are  rather  rare  tumors,  even  in  the 
negro  race.  They  do,  however,  occasionally  occur,  usually  as  soli- 
tary tumors  in  adults.  They  are  occasionally  found  upon  the  ab- 
domen, arising  from  the  sheaths  of  the  recti  muscles.  Fibromata  of 
the  tendon  sheaths  are  also  sometimes  encountered.  The  growths 
are  usually  small,  sharply  circumscribed  hard  nodules,  that  are  round 
or  oval  in  shape.  Fibromas  always  have  a  certain  tendency  to  de- 
generate into  sarcomas,  so  should  always  be  removed,  preferably  by 
excision. 

FIBROMA  MOLLUSCUM. 

The  fibroma  moUuscum,  also  called  neurofibroma  and  von  Keck- 
linghausen's  disease,  is  a  tumor  derived  from  the  sheath  of  a  cuta- 
neous nerve.  The  growths  are  usually  multiple,  and  are  accompanied 
in  many  instances  by  telangiectases  and  pigmented  areas.  The  sub- 
jects are  frequently  below  par  mentally.  The  growths  are  often 
rather  soft  to  the  touch,  and  they  may  be  of  a  distinct  violaceous 
color.  They  are  occasionally  very  painful  to  pressure.  The  groAvths 
do  not  tend  to  disappear  spontaneously:  in  fact,  the  reverse  is  often 
true,  and  malignant  degeneration  may  occur  in  them.  In  some  in- 
stances these  tumors  are  solitary  and  are  then  pendulous,  and  often 
of  great  size.  Surgery  alone  is  useful  in  the  treatment  of  this  af- 
fection. Neither  the  x-ray  nor  radium  have  proven  of  any  value  in 
handling  these  lesions,  nor  has  internal  medication  influenced  them. 


3  Anderson:  Lancet.  18SS.   i,   1025. 

••Adamson:  Brit.  Jour.  Dermat..  1914,  xxvi,  C9. 


134  >MN   r\Mi:i{. 

NEUROMA. 

According  to  lleicliiigsfeld,^  very  few  cases  of  neuroma  cutis  liave 
been  described.  In  the  cases  reported  by  this  autlior  and  in  others 
which  he  luis  .}]:athered  from  the  literature,  tiie  tumors  were  usually 
solitary,  hut  were  I'arely  multiple,  and  ai)peai'cd  clinically  as  sub- 
cutaiu'ous  nodules  tliat  could  readily  he  mistaken  for  either  fibromas 
or  myomas.  Pivssure  upon  these  fjrowtlis.  however,  usually  jiave 
rise  to  laiiciuat  iiiLi'  pains.  1 1  i.sloloLiically,  cxamiiial  itui  I'cvcaled  the 
presence  of  nerve  tissue,  sometimes  associated  with  either  muscle  or 
endothelial  tissue.     Surgical   intei'vention  was  curative. 

MYOMA. 

This  rare  tumor  of  the  skin  has  Ijeen  carefully  studied  l)y  ITeid- 
ingsfeld.''  The  growths  ma>'  take  their  origin  from  the  nniscle  nor- 
mally present  in  the  walls  of  the  vessels,  in  the  arrector  ])ili  mu.scles, 
or  in  the  musculai-  attachments  to  the  glands.  Clinically,  they  are 
subcutaneous  single  or  multiple  tunuirs  that  are  apt  to  be  painful 
upon  pressure.  In  some  instances  they  are  associated  with  cavern- 
ous dilatation  of  the  blood  vessels.  They  can  be  diagnosed  with  cer- 
tainty only  by  microscopical  examination.  Surgical  intervention  is 
curative. 

LIPOMA. 

Lipomas  or  fatty  tumors  arc  probably  the  commonest  benign  tu- 
mors that  are  encountered  in  surgical  dispensaries.  They  some- 
times develop  in  children,  but  much  more  commonly  in  adults.  The 
solitary  forms  are  much  commoner  than  the  multiple  or  diffuse. 
They  may  be  found  upon  any  portion  of  the  body.  They  vary  great- 
ly in  size,  from  being  almost  microscopic  to  a  weight  of  several 
pounds.  They  have  their  origin  in  the  subcutaneous  fatty  tissue. 
There  are  several  types — the  solitary,  the  multijile,  and  the  diffuse. 
The  latter  condition  is  often  spoken  of  as  "fatty  neck."  Lipomas 
do  not  become  malignant,  and  are  not  dangerous  in  any  sense.  i)ut 
are  rather  unsightly.  They  may  be  easily  removed  ])y  sui-gical  in- 
terference, and  do  not  recur  if  completely  removed. 

OSTEOMA. 

True  bony  tumors  of  the  skin  must  be  differentiated  from  cal- 
careous deposits  which  are  the  result  of  chronic  inflammatory  proc- 


=  Heiding.><fel<J:  .lour.   Amer.   Med.   Assn.,   1913,   Ixi.   405. 
•  Heidiiigsfeld:  Jour.  Air.er.  Med.  A.ssn.,  1907,  xlviii.  562. 


BENIGN  cONNKr-nvi:  'I'lssii:  'itmoks.  135 

CSSGH.  lloidinfji'.st'cid"  li;is  hficMy  reviewed  .some  of  1  licso  fasoH  in  Jul- 
ditioil  to  reportiiiijj  ojk;  of  liis  own.  The  </towtliH  pi'o});ibly  nrisc 
from  eonsenitally  luisplafed  hone  eells.  'I'lie  <4r()wtlis  -.n-c  ;ilu'ays 
.small,  juid  usunlly  occur  in  eonneclion  with  oilier  lesions.  Ifislo- 
logically,  tlicy  .show  typical  hone  si  met  nr<\  They  ni;iy  he  removed 
by  operation. 

HEMANGIOMA. 

A  hemangioma  or  vascular  iie\iis  is  a  eongeuilMl  ji(;vv  growth  ;ind 
hypertrophy  of  the  blood  vessels  of  the  skin.  .Sni;ill  telangiectases 
are  frequently  acquired,  but  the  larger  lesiojis  aic  always  congeni- 
tal. Unna  is  inclined  to  believe  that  external  pressure  during  in- 
trauterine life  is  ]-esponsible,  Avhile  still  o1hei-s  have  thought  that 
nerve  changes  might  be  responsible,  jjiasiiiuel;  ;is  Ihey  frequently  de- 
velop along  the  distribution  of  a  nerve. 

Several  groups  must  be  recognized.  First,  the  small  telangiectatic 
spots;  second,  the  flat  nevi;  thii'd,  the  nevi  containing  spongy  tis- 
sue of  a  somewhat  erectile  character  and  that  protrudes  consider- 
ably above  the  surface  of  the  skin;  and  fourth,  the  racemose  aneu- 
rysms. The  second  class  usually  remain  stationary,  but  the  mem- 
bers of  the  other  three  groups  may  grow  to  a  considerable  extent, 
so  should  always  be  kept  under  observation.  Occasionally  a  sar- 
coma may  develop  from  one  of  these  lesions. 

The  smaller  telangiectases  can  be  removed,  if  this  be  considered 
advisable,  by  either  the  electric  needle  or  by  carbon  dioxide  snow. 
The  pale  flat  nevi  should  be  left  alone,  and  even  the  dark  ones  are 
difficult  to  handle  satisfactorily,  although  many  claims  have  been 
made  for  the  Kromayer  lamp,  claims  that  not  all  dermatologists  are 
willing  to  concede.  Eadium  is  not  satisfactory,  as  it  acts  by  pro- 
ducing scar  tissue.  Mild  freezing  with  carbon  dioxide  snow  is  at 
times  beneficial.  The  large  protruding  nevi  are  probably  best 
treated  by  means  of  the  snow,  this  being  undoubtedly  much  better 
than  injections  of  boiling  water  or  scarification  with  the  cautery. 
The  racemose  aneurysms  should  be  treated  by  surgical  methods. 

LYMPHANGIOMA. 

As  Stelwagon^  well  points  out.  the  subject  of  lym]ihangioma  is 
still  a  rather  confused  one,  inasmuch  as  no  hard  and  fast  dividing 
line  has  been  drawn  between  actual  new  growths  and  lymphangiec- 
tases. 


'  Heidingsfeld:  Arch.   f.  Dermat.   u.   Syphil..   190S.  xcil,   337. 
s  Stelwagon:  Diseases  of  the  Skin.  7th  ed..   661. 


136  SKIN    CANCER. 

Lymphangioetascs  may  be  observed  in  either  the  sui^erficial  or 
deep  lymphatics.  The  superficial  form  appears  as  minute  or  slight- 
ly larger  vesicles.  Avhich.  when  ruptured,  give  a  discharge  of  lymph. 
The  deep  variety  is  usually  secondary  to  some  inflammatory  proc- 
ess, and  can  be  recognized  only  as  a  corded  groAvth  beneath  the 
skin. 

Simple  lymphangiomata  occur  as  circumscribed,  slightly  elevated 
tumors,  consisting  of  enlarged  lymphatics.  The  forms  best  known 
are  in  the  tongue  or  lip,  the  former  being  known  as  macroglossia  and 
the  latter  as  maerochelia. 

Lymph  cysts  are  deep  cystic  tnnioi-s  that  come  under  the  domain 
of  surgery. 

Lymphangiomata  may  l)e  the  seat  of  a  latter  sarcoma,  so  should 
always  be  removed  Avhen  possible. 

LYMPHANGIOMA   CIRCUMSCRIPTUM. 

This  disease  is  characterized  by  a  hypertrophy  and  new  growth 
of  lymph  capillaries,  characterized  by  circumscribed,  elevated,  crowded 
vesicles  filled  with  lymph.  As  a  general  rule,  the  disease  begins  early 
in  life,  so  may  be  due  to  a  congenital  defect.  As  a  general  rule, 
there  is  but  one  patch  present,  and  this  usually  occurs  upon  the 
limbs,  neck,  or  upper  portion  of  the  l)ody.  The  vesicles  are  firm  and 
not  easily  ruptured.  The  pathology  has  been  well  studied  by  Gil- 
christ.^ These  lesions  can  be  easily  removed  with  the  actual  or  elec- 
tric cautery. 


'Gilchrist:  Bull.  Johns  Hopkins  Hospital,  1896,  138. 


CHAPTER  XIII. 

SARCOMATA  AND   SARCOIDS. 

SARCOMATA. 

The  subject  of  sarconuita  ui"  the  skin  is  si  ill  ifi  ;i  gi'(-al]y  con- 
fused condition.  It  is  not  yet  definitely  known  wlicilicr  the  multiple 
pigmented  growths  arc  derived  from  the  epithelium  or  from  the 
mesoblastic  structures,  and  neither  is  it  definitely  decided  whether 
many  of  the  alveolar  growths  are  endotheliomata  or  sarcomata. 
Again,  the  dividing  line  between  the  sarcomata  and  certain  so-called 
cases  of  mycosis  fungoides  and  lymphoid  tumors  is  a  very  shadowy 
one,  and,  last,  certain  cases  of  sarcomata  cannot  be  definitely  dis- 
tinguished from  certain  of  the  sarcoid  tumors.  Until  these  growths 
can  be  distinguished,  or  until  they  can  all  be  proven  to  be  merely 
different  forms  arising  from  the  same  cause,  the  subject  must  of 
necessity  remain  hazy. 

In  a  short  chapter  of  this  kind  it  seems  best  not  to  attempt  to 
reconcile  all  of  these  differences,  but  rather  to  point  out  that  they 
do  exist,  and  to  describe  the  well-known  and  typical  forms  of  this 
very  serious  type  of  cutaneous  neoplasm. 

The  following  classification  is  tentatively  adopted : 

Sarcomata. 

Solitary  lesions. 
Round-celled. 
Spindle-celled. 
Giant-celled. 

Multiple  lesions. 
Round-celled. 
Melanotic. 
Pigmented  hemorrhagic   (Kaposi). 

Transitional  type. 

Spiegler-Fendt  sarcoids. 

Sarcoids. 

Boeck  type. 

Subcutaneous  type  of  Darier  and  Roussy. 
Nodular  type  on  extremities. 

137 


138  SKIN    CANCER. 

SOLITARY  LESIONS. 

Round-Celled. — The  small  round-celled  sarcomata  are  extreme- 
1\  iiialiiifnant :  for  it  is  a  ])Oi'uliai-ity  of  sarcomata  that  the  nearer 
they  a])i)roach  the  embryonic  type  of  cili  in  struct  mo  the  more  nui- 
lignaut   they  arc. 

Incidence. — The  lesions  are  relatively  uncommon,  and  the 
majoiity  of  dermatologists  have  not  seen  more  than  half  a  elozen 
cases.  The  disease  only  rarely  arises  de  novo;  it  usually  commences 
in  the  scar  of  a  burn,  in  a  nevus,  either  vascular  or  i)i.<;mcntod.  or 
in  some  other  abnormality  of  the  skin.  Bloodji:ood,'  in  discussing 
the  etiology  of  sarcomata  of  tlu'  skin  in  general,  states:  "Among 
forty  cases  of  sarconui  of  the  skin  there  was  a  distinct  precancerous 
lesion  in  thirty-two.  These  lesions  were  as  follows:  Congenital  nevi, 
six;  scars,  nineteen:  fibromas,  seven."  Bloodgood  further  states  that 
the  more  nmlignant  tumors,  which  he  is  pleased  to  call  perithelial 
angiosarcomata,  but  which  arc  probably  to  bo  classed  under  the  oat- 
shaped-cellcd  heading,  frequently  develop  from  a  congenital  nevus, 
trauma  usually  starting  the  new  growth.  In  cvci->-  instance  a  fun- 
gous tumor  develops,  usually  very  rapidly. 

Clinical  Course. — Clinically,  there  are  two  tyi)es  of  tunu)i- — 
(1)  where  a  nodule  ai)]iarently  begins  in  the  normal  skin,  and  (2) 
where  a  nevus  Ijreaks  down.  In  the  first  type  it  is  noted  that  a 
pale-red.  rather  vascular,  nodule  begins  to  ])rotrude  from  the  skin, 
and  that  it  bleeds  very  easily  on  injury.  The  lesion  is  usually 
round  at  the  start,  and  may  project  above  the  skin,  or  may  be  be- 
neath it,  according  to  the  dei)th  of  the  tissue  from  \\hich  it  sprang. 
Ulceration  usually  takes  place,  in  the  center  of  the  growth  at  least. 
In  the  deep  type  there  is  considerable  induration,  but  not  of  the 
stony  character  so  typical  of  carcinonuita.  Crowth  nuiy  be  slow  or 
very  rapid,  and  metastasis  to  the  glands  often  takes  place  within 
a  few  weeks  after  the  first  appearance  of  Ihe  tumor  is  noted.  It  is 
not  infi-eriuent  to  find  a  few  metastases  in  the  neighboring  skin. 

Pathology. — Pathologically,  the  cells  are  either  small  oi'  laige 
round  cells  (Fig.  55)  that  may  or  may  not  be  divided  into  islands 
by  fibrous  tissue.  ^Mitotic  figui-cs  are  very  common.  Usually  there 
is  but  little  inflammatory  exudate  around  the  edges  of  the  invad- 
ing gi'owth.  Unna-  has  some  very  interesting  ideas  as  to  the  origin 
of  the  sai-coma  cells.  He  holds  that  the  degeneration  begins  in  the 
healthy  tissue  with  a  swelling  of  the  spindle  cells;  these  cells  soon 


'Bloodgood:  Progressive  Medicine,  Dec,   1912. 
=  Unna:  Histopathology  of  Diseases  of  the  Sliin. 


SARCOMATA.  139 

withdj'aw  thcii;  proccsscis,  hfi^oiiK;  round  (ti-  (■\{\)]c;i\.  ;iti(|  often  forin 
true  ])];i.sina  onlls.  3^^'oni  1li(;iii,  iic.ar  Ihf.  Mi;ir<^in  f)i'  the  mow  j^rowlh, 
the  ti'iio  sai'C'onia  ocIIh  develop.  'JMiiis  the  fthiHina  eells  are  a  sta»^e 
ill  tlie  (h'velopnicnt  ol'  round-celled  s;ireoin.a,  frotn  s[)in(|lcd-oelled 
niesoblastie  structures. 

Diagnosis. — ^The  sarcomata  oI  tiiis  type  must  be  distinj^uislied 
fj'oni  cndotheliomata,  granuloma  pyogenicum,  and  various  adenomata 
of  the  skin  structures.  In  case  of  doubt  the  new  gr-ovvth  should  be 
removed  by  a  broad  excision,  and  submitted  to  histological  examina- 
tion. Usually,  however,  diagnosis  is  not  difficult,  for  in  sarcoma  the 
growth  is  more  rapid,  and  there  may  be  early  ulceration  of  the  skin. 

The  sarconuita,   originating  from   nevi,   resemble   the   group   fir.st 


Fig.    55. — High-power   ijhotomicrograph   ui    small   round-celled    sarcoma   of   skin. 

(Author's  collection.) 

described,  except  in  their  origin  and  early  appearance.  At  first 
it  is  noticed  that  the  nevus  is  enlarging,  and  ulceration  speedily 
takes  place.  Then  a  fungous  tumor  usually  protrudes  from  the  area 
of  ulceration,  and  the  further  course  is  as  already  described. 

Prognosis  and  Treatment. — The  prognosis  is  bad.  Bloodgood 
states  that  only  one  of  his  six  cases  was  cured  by  operation.  Opera- 
tion should  consist  of  Avide  local  excision,  and  removal  of  the  neigh- 
boring glands  at  the  same  time,  using  a  block  operation,  so  that  all 
tissue  is  taken  out  in  one  place. 

Spindle-Celled. — The  spindle-celled  sarcomata  are  much  com- 
moner than  are  the  round-celled  neoplasms  for  the  reason  that 
mesoblastic  tissue  is  normally  composed  of  spindle  cells.     Different 


140  SKIN    CANCER. 

grades  of  malignancy  exist,  according  to  Mhethcr  the  tumor  con- 
sists of  fibro-spindle  colls,  or  of  the  jnire  oat-shaped  or  spindle  cells. 
Incidence.— This  group  of  tumors  frequently  arises  from  the  scars 
of  old  wounds  or  burns,  especially  those  that  have  healed  slowly. 
Bloodgood  states  that  he  has  never  seen  a  nudignant  neoplasm  aris- 
ing from  a  wound  that  has  healed  by  first  intention.  These  tumors 
sometimes  arise  from  preexisting  fibromata. 

Clinical  Course. — The  tumors  appear  as  firm  "white  or  pinkish 
growths,  lliat  usually  grow  rather  rapidly.  There  is  usually  con- 
siderable dilatation  of  the  surface  blood  vessels,  and  idceration  takes 
place  early.  The  neighboring  glands  usually  become  involved  with- 
in one  year.  At  times,  when  a  glandular  enlargement  is  found, 
this  is  not  due  to  metastases  of  the  sarcoma  cells,  but  to  inflanmia- 
tion. 

Pathology. — Pathologically,  the  cells  consist  of  various  types  of 
spindle  colls.  In  some  cases  these  approach  fibrous  tissue  in  char- 
acter, and  in  other  cases  are  short  and  oat-shaped ;  the  latter  are 
much  more  malignant.  These  cells  are  arranged  in  bundles  that  in- 
tersect the  growth  at  all  angles,  and  forming  a  sort  of  frame  around 
the  blood  vessels,  which  are  dilated.  Some  blood  pigment  may  be 
deposited  in  the  tissue,  chiefly  around  the  vessels.  Mitotic  figures 
are  rarely  seen.  A  few  plasma  cells  are  usually  found  scattered 
among  the  spindle  cells,  chiefly  near  the  edge  of  the  growth.  The 
elastic  tissue  is  lost  at  once  and  the  normal  lymphatics  are  obliterated. 
There  is  no  inflammatory  reaction  as  occurs  in  carcinoma.  Certain 
of  these  tumors  undoubtedly  have  their  origin  in  the  blood  ves- 
sels, and  hence  deserve  to  be  called  angiosarcomata,  but  all  tumors 
of  this  class  do  not  arise  in  this  way.  For  a  fuller  discussion  of 
the  pathology  of  these  neoplasms  the  reader  is  referred  to  the  work 
of  Unna,  which  is  very  complete,  and  gives  an  excellent  bibliog- 
raphy. 

Diagnosis. — This  group  of  tumors  is  easy  to  diagnose,  largcl.v 
because  of  the  early  ulceration. 

Prognosis. — The  prognosis  is  much  better  than  in  the  other  va- 
riety of  sarcomas,  although  by  no  means  as  good  as  might  be  de- 
sired. Bloodgood  states  that  in  nineteen  cases  six  have  remained 
well  after  operation,  although  most  of  these  were  fairly  well  ad- 
vanced cases.  If  the  cases  can  be  operated  upon  early,  at  least  50 
percent  should  be  saved. 

Treatment. — If  seen  early,  a  broad  local  excision,  probably  -with 
removal  of  the  neighboring  glands,  should  1)0  the  method  employed. 


SAKCOMA'IA.  141 

Neither  radium,  the  x-j-ay,  Jior  any  of  the  ffiii.slifs  slioul'l  he  used, 
except  ill.  inoperable  neoplasioH. 

Giant-Celled. — Giant-eelled  sareonuis  of  the  skin  are  extremely 
rare,  although  a  few  instances  have  been  recorded. 

Unna  reports  a  case  where  there  was  a  small,  bluish-red,  angioma- 
like  tumor  of  the  face.  Unna  says:  "The  whole  cutis  was  ti-aris- 
formcd  into  a  tumor  mass,  witli  niimerous  cells  and  very  little  inter- 
cellular substance,  over  which  tlie  ('i)idei-niis  was  here  and  there 
thijincd,  and  in  one  place  ulcei'ated.  ...  It  was  evident  that 
the  tumor  cells  developed  from  spindle  cells,  Avhich,  by  taking  up 
protoplasm,  at  first  around  the  nucleus,  enlarged,  and  then  assumed 
all  ])ossible  forms  and  dimensions.  The  cells  are  so  multiform  that 
it  is  hardly  possible  to  describe  them.  .  .  .  Almost  all  of  them 
contain  several  nuclei.  They  passed  very  gradually  into  giant  cells, 
with  which  every  section  swarmed." 

Pasini^  has  recently  reported  a  case  of  giant-celled  sarcoma  of 
the  skin,  and  both  Crocker*  and  Perrin  and  Leredde'  have  reported 
instances  of  sarcomatosis  of  the  cutis  from  giant-celled  neoxdasms. 
These  last  reports  seem  rather  singular,  for  a  priori  one  would  hardly 
suspect  that  a  growth  showing  the  characteristics  of  a  giant-celled  sar- 
coma would  be  so  malignant.    In  other  regions  they  certainly  are  not. 

Treatment. — The  treatment  should  consist  of  ample  local  excision, 
and  not  of  caustics  or  x-rays,  except  perhaps  as  an  adjunct  to  the 
knife. 

As  regards  the  local  treatment  of  extensive  or  inoperable  sarco- 
mata, but  little  can  be  said.  Wickham  has  had  some  really  remark- 
able results  with  radium.  Those  who  have  seen  the  photogi'aphs  that 
he  exhibited  at  the  International  Dermatological  Congress  held  at 
Eome  in  1912  were  wonderfully  impressed  wdth  his  success.  A  few 
good  results  from  the  x-ray  have  been  reported,  but  they  have  not 
been  constant.  So  far  as  general  treatment  goes,  (.^ley's*^  serum 
should  be  tried,  although  Coley  has  had  rather  better  results  than 
others  who  have  used  the  preparation.  Coley 's  serum  consists  of  a 
vaccine  made  from  the  streptococcus  of  erysipelas  and  the  bacillus 
prodigiosus.  The  rationale  of  the  treatment  is  as  follows :  Some 
3'ears  ago  it  was  noted  that  when  a  patient  suffering  from  sarcoma 
w^as  attacked  by  erysipelas,  the  result  upon  the  neoplasm  Avas  most 
beneficial ;  this  led  some  clinicians  to  inoculate  their  hopeless  sar- 


spasini:  Gior.  Ital.  d.  Mai.  Yen.   e.   d.   Pel.,  1912,  liii,  353. 

*  Crocker:  Diseases  of  the   Skin. 

=  Perrin  et  Leredde:  Ann.   de  Dermat.  et  de  Syphil.,  1895,  vi.   103S. 

«  Coley:  Amer.   Jour.   Med.   Sc,  1893,   cv,  4S7;   1906,   cxxxi,   375. 


142  SKIN    CANCER. 

coma  patients  with  erysipelas,  but  tlic  results  of  the  infeotion  were 
fre(iuently  so  disastrous  that  Coley  detei-mined  to  try  vaecines,  and 
in  some  instances  his  results  were  excellent.  Coley  himself  does  not 
advise  the  use  of  the  serum  upon  operable  cases. 


Fig.    56. — Multiple    sarcomata.      (C.    J.    White's    collection.) 

MULTIPLE  LESIONS. 

Round-Celled. — Sarconiatosis  of  the  skin,  except  with  melanotic 
growths,   is  very   unusual.     When  this  condition   does  occur,   it  is 


SARCOMATA.  143 

UHUally  with  the;  smnll  roiind  <'i'llc<I  lyi**'  of  lu-opLiHin,  for  tliis  is 
the  most  iTialif^niJiiii  vnricly.  'lMi<'  followiii^^  iii;iy  Ik-  1;ikcii  ;is  a  tvfd- 
cal  example:  Pjiiicni  was  a  wliilc  iiuni  ;i^m(|  M,  who  li;i<!  ;ilv.;iys 
enjoyed  the  l)est  of  licjillli  mitil  six  moiitlis  [)rc,vioiisly,  when  small 
nodules  began  to  appear  uj)oji  his  scalp,  shortly  followed  by  their 
development  upon  trunk  and  limbs.  Examination  reveale*!  a  healthy 
looking,  strongly  built  iiKiii  who  looked  the  picture  of  hf;illh.  All 
over  his  body  there  were,  howevci-,  ;it  Icfist  two  hunrlred  small  cuta- 
neous and  subcutaneous  nodules,  usunlly  nhoul  1  fin.  in  diameter, 
but  a  few  were  4  to  5  cm.  in  diatnetei-.  Tluji'e  was  no  ulceration  of 
the  skin  over  them.  Tumors  wei-e  fi-cely  movable  in  the  skin,  and 
were  rather  firm  to  the  touch.  There  was  no  marked  dilatation  of 
the  surface  vessels.  In  the  groin  there  were  a  number  of  enoi"mousl\- 
enlarged  glands.  Excision  of  one  of  the  small  growths  showed  a 
typical  small  round-celled  sarcoma.  In  other  instances  the  tumors 
are  much  fewer  in  number  and  may  be  compai-atively  large.  It  is 
rare  to  find  a  spindle-celled  sarcomatosis  of  the  skin  except  in  tu- 
mors of  the  multiple  hemorrhagic  variety.  The  outlook  is  hope- 
less; neither  Coley's  serum  nor  x-ray  has  any  effect,  and  patients 
usually  die  within  a  year. 

Melanotic. — The  multiple  melanotic  groAvths,  so  frequently  called 
melanotic  sarcomata,  have  already  been  described  in  another  chap- 
ter. 

Pigmented  Hemorrhagic  (Kaposi). — The  multiple  i^igmented  hem- 
orrhagic sarcoma  of  Kaposi"  is  rather  a  curious  lesion  in  many  re- 
spects, for  it  lacks  the  malignancy  of  a  true  spindle-celled  sarcoma, 
although  composed  of  that  variety  of  tissue ;  at  times  it  seems  to 
heal  spontaneously,  and  may  be  related  to  the  sarcoid  group  of  tu- 
mors. 

Incidence. — The  disease  is  rather  rare  in  both  England  and  Amer- 
ica, although  cases  in  the  latter  country  have  been  described  by 
Fordyee,'  Hyde,°  Hartzell,^°  and  others.  In  continental  Europe  it 
is  much  commoner.  Kaposi  has  had  over  thirty  cases.  De  Amicis^^ 
in  Italy  over  fifty,  and  many  have  been  reported  from  Austria  and 
Kussia.  In  America  it  occurs  most  commonly  in  Jewish  immigrants, 
which  might  seem  to  speak  for  its  infective  nature. 


"Kaposi:  Kaposi  and  Hebra,  Dis.  of  Skin,  Xew  Sydenham  Soc.  Translation,  Lon- 
don. 1875. 

sFordyce:  Jour.   Cut.  and  Gen.  Urin.  Dis.,  1S91,  ix,  1. 
^Hyde:  Quoted  by  Crocker. 
"Hartzell:  Jour.  Cut.  Dis.,  1908,  xxvi,  97. 
^1  De  Amicis:  II  Morgagni,  1872. 


144  SKIN    CANCER. 

Clinical  Course.— Tlic  iifllk'tiDii  ahvay.s  be!J:ins  on  eitlier  the  liands 
or  iVct.  iLsually  the  dorsal  surface.  At  first  an  edema  is  noted,  then 
bluish  spots  appear,  in  the  center  of  wliich  are  nodosities.  The  tu- 
mors slowly  increase  in  both  size  and  number,  usually  traveling  up 
the  limb.  The  neoplasms  are  either  round  or  flat,  are  dark-red  at 
first,  then  ])uri)lo,  and  then  brown.  The  color  is  due  to  hemorrhage 
and  the  deposit  of  blood  i)i!i:ment.  Tlicy  vary  in  number  from  twen- 
ty to  several  Inmdred,  and  in  size  from  1  em.  to  15  cm.  (Fig.  57). 
They  may  be  liard  or  soft,  and  usually  l)leed  readily  when  punctured. 
The  general  health  is  not  affected  for  several  years,  and  in  the  early 
stages  there  is  no  glandular  involvement.  The  patients  idtimately 
die  from  general  sarcomatosis.  ^Maiiani^-  has  given  the  best  sur- 
vey of  the  subject,  including  literature,  yet  extant.  It  is  to  be 
noted  that  these  tumors  grade  off  into  the  Spieglcr-Fendt  type,  usual- 
ly called  sarcoids,  and  also  described  by  Polland  as  comparatively 
beniirn  sarcomata. 

Pathology. — Histologically,  there  may  be  seen  numerous  large 
cavities  tilled  with  blood,  the  space  between  the  cavities  being  com- 
posed of  parallel  rows  of  spindle  cells,  between  which  is  deposited 
much  pigment.  Traces  of  hemorrhages  may  be  seen  in  places.  This 
picture  has  been  interpreted  by  some  as  the  result  of  infection — 
that  is,  that  the  tumor  is  in  reality  a  granuloma — and  by  others  as 
a  i>ure  sarcoma  of  a  special  type,  the  latter  view  predominating. 

Treatment. — Treatment  is  not  satisfactory.  According  to  Kob- 
ner,^^  Sherwell,^*  and  De  Amicis,  arsenic  will  cure  some  cases  if  given 
in  large  amounts  and  over  a  considerable  space  of  time,  Fowler's  so- 
lution being  the  form  generally  employed.  Possibly  cacodylate  of 
soda,  used  intramuscularly,  might  produce  a  better  effect,  and  yet 
one  must  be  inclined  to  agree  with  Fox  and  AVile,  who  believe  that 
arsenic  cures  only  sarcoids  and  not  true  sarcomata.  X-ray  is  use- 
ful in  certain  cases,  though  probably  not  for  any  great  length  of 
time.  One  observer  has  reported  the  disappearance  of  the  lesions 
following  the  local  application  of  bichloride  solutions. 

TRANSITIONAL  LESIONS. 

Spiegier-Fendt  Type. — Tumoi-s  of  the  variety  descri])ed  by  Spieg- 
ler,^"  j.\.ji,]l  !■■  l>()]laii(l,''  and  others,  and  commonly  called  the  Spieg- 

"Mariani:  Arch.  f.  Dermat.  u.  Syphil.,   1909,  xcviii,  267. 

"  Kobner:     Berl.   med.  Wchnschr.,   1883,  No.  2. 

"Sherwell:  Amer.  Jour.  Med.  Sc,  Oct.,  1892. 

•-  Spiegler:  Arch.  f.  Dermat.  u.   Syphil.,  1894,  xxvii,   163. 

'■=Fendt:  Arch.   f.   Dermat.    u.    .Syphil.,   1900,   liii,   213. 

1"  Polland:  Arch.    f.   Dermat.   u.   Syphil.,   1910,   civ,    09;   1912,   cxi,   69. 


SARCOMA 'I' A. 


145 


Icr-Fcndt  1\|m'  of  snrcoid,  seem  lo  neeiipy  ;iii  i lit (■niierlijito  position 
between  tlie  Kaposi  ly|)e  of  iiiillli|ile  s;ireoiii;i  jiinl  1  he  eoinfirirativcly 
hfiTtnless  s;ii'e(»i(ls. 

Ill    lliis    ^Toilp    of    lesidiis    ;ire    |Hir|ilisli  Vi'd    liiinors,    ii.sii;ill\-    Iviiij? 


Fig.    57. — Multiple   hemorrhagic    sarcoma    (Kaposi).      (HeidingsfelcVs    collection.) 


14G  SKIX    CANCF.R. 

deep  in  the  cutis,  essentially  chronic  in  course,  showinfr  no  ulcera- 
tion, and  almost  invarialily  ^i^nng  no  metastases,  although  Spiegler 
has  reported  one  fatal  ease.  Histologically,  there  are  more  or  less 
circiunscribed  areas  of  small  round-colled  infiltration.  These  ag- 
gregations may  be  inclo.sed  in  a  connective  tissue  caiisule.  At  times 
a  few  giant  or  eiiithclial  cells  may  occur.  Fox  and  AVile'^  very  per- 
tinently remark:  "It  is  highly  probable  that  many,  if  not  all.  of 
the  so-called  cured  cases  of  sarcomatosis  cutis  belong  to  this  group, 
which  is  really  distinguished  from  true  sarcomatosis  cutis  by  the 
extreme  malignancy  of  the  latter  and  its  tendency  to  invade  the 
inner  organs." 

SARCOIDS. 

The  i-ather  lengthy  ai-tidos  by  Fano'"'  and  Darior-°  are  extremely 
helpful  in  dealing  with  the  problem  of  the  border  line  conditions  be- 
tween the  sarcomata  and  sarcoids. 

Boeck  Type. — The  Boeck^^  type  of  sarcoid  is  probably  the  best 
known  and  the  most  often  diagnosed.  It  may  occur  as  one  or  more 
large  nodules,  as  numerous  papules,  or  in  infiltrated  placques,  us- 
ually developing  upon  the  face,  back,  shoulders,  or  arms.  There  are 
practically  no  subjective  symptoms,  and  the  general  health  is  un- 
affected. The  nodules  are  pink  or  purplish  in  color,  and  often  show- 
dilated  peripheral  vessels,  and  there  may  be  slight  scaling.  To  the 
touch  they  are  firm  and  elastic,  but  there  is  no  deep  infiltration. 
The  lesions  run  a  chronic  course  and  never  ulcerate.  They  may  in- 
volute spontaneously. 

Histologically,  the  sections  show  sharply  circumscribed,  deep- 
seated  nodules,  composed  of  epithelioid  cells,  filling  the  perivascular 
lymph  spaces.  At  the  periphery  one  may  observe  lymphocytes  and 
a  few  giant  and  plasma  cells.  There  is  no  evidence  of  caseation  ne- 
crosis, although  Boeck  considered  the  lesions  to  be  tuberculous  in 
origin. 

T1i(^   lesions   iiivoluto   nnd(M"   proloimod    administration   of   arsenic. 

Subcutaneous  Type  of  Darier  and  Roussy. — The  type  of  sarcoids 
described  by  Darier  and  Eoussy--  is  rare  and  occurs  only  upon  the 
trunk.  There  are  found  lesions  of  about  1  to  5  cm.  in  diameter, 
distinctly  round  or  oval.     The  nodules  are  composed  of  epithelioid 


"Fox  and  Wile:  Jour.   Cut.   Dis.,   1911.   xxix,   375. 

"Fano:  Arch.  f.  Dermat.   u.   Syphil..   1007,  Ixxxiii,   33,   225,  427. 

'•Darie:-:  Monat.sh.  f.  prakt.  Dermat.,  1910,  1,  419. 

«  Boeck:  Jour.  Cutan.  and  Gen.-Urin.  Dis.,  1899,  xvii.  543. 

Arch.   f.  Dermat.  u.   Syphil.,  1905,   Ixxiii,  71. 
"Darier  et  Rous.sy:  Ann.   de    Dermat.   et   .Syphil.,   1904,   v.    144,    341 


SARCOIDS.  147 

cells  and  I yinpliocylcs  and  numerous  jjiaiil  '•(■lis.  TIk;  chanji^eM  arc 
less  circiiniscrihcd  than  in  1  he  liocck-  lypc,  anri  ;it  linif-s  Sf;f;m  to  be 
disliiK'tly  infiltrating. 

Nodular  Type  on  Extremities.  Tlic  last  type,  suggested  by 
Darici-,  i-csoinblcK  the  erythema  indiiraluni  of  Bazin ;  in  fact,  the 
following  name  has  been  su<,'f,'ested,  "sai-eoides  noin-uses  et  nodul- 
aires  des  membrcs."  The  lesions  usually  develop  upon  1he  le^s  of 
adult  women,  and  present  reddish  or  i)ni'plish  nodules  or  iiiflltra- 
tions.  It  is  very  diffieult  to  separate  this  ^ronp  from  true  cases  of 
erythema  induratum,  especially  as  this  1yp('  ol'  sarcoids  may  occa- 
sionally ulcerate. 

Darier  especially  i)oiuts  out  that  all  cases  of  sarcoids  do  not  run 
true  to  form,  and  that  one  case  may  show  featui"es  of  several  of  these 
groui)s,   either  clinically   or  histologically. 

Etiology. — \n  regard  to  etiology,  there  are  two  views — one  that 
the  affection  is  of  tuberculous  origin,  and  the  other  that  it  is  not. 
In  favor  of  the  tuberculous  etiology  may  be  cited  the  microscopic 
findings,  the  epithelioid  and  giant  cells,  although  the  author  by  no 
means  admits  that  the  presence  of  giant  cells  makes  a  diagnosis  of 
tuberculosis  certain,  for  they  can  be  found  in  almost  any  chronic 
infiannnatory  condition  of  the  skin,  even  down  to  acne  vulgaris. 
Winckler,-'^  in  an  analysis  of  seventeen  cases,  found  evidence  of  tu- 
berculous deposits  in  the  body  in  six  cases,  and  that  about  ten  cases 
out  of  thirty-one  reacted  positively  to  tuberculin,  a  figure  not  much 
more  than  the  general  average  of  supposedly  healthy  persons.  A 
positive  inoculation  experiment  has  been  recorded  by  Morawitz.-* 
On  the  other  hand,  Kren  and  Weidenfeld"  made  inoculation  experi- 
ments in  two  cases  with  negative  results.  Histologically  and  clin- 
ically, there  is  no  evidence  of  caseation  or  necrosis,  which  fact  is 
very  unlike  those  usually  observed  in  tuberculosis  of  the  skin.  Ar- 
senic will  cure  sarcoids  and  will  not  cure  tuberculosis. 

Diagnosis. — From  the  standpoint  of  differential  diagnosis,  it  is 
at  times  extremely  difficult  to  exclude  sarcomatosis  cutis,  only  the 
course  of  the  disease  serving  to  do  that.  Leukemia  cutis,  leprosy, 
and  syphilis  can  be  differentiated  by  the  various  laboratory  tests  in 
case  of  doubt. 

Prognosis  and  Treatment. — The  prognosis  for  both  life  and  the 
local  betterment  is  good.  Arsenic  has  a  remarkable  effect,  although 
it  must  frequently  be  used  over  a  long  space  of  time.  Darier  thinks 
that  the  x-rav,  calomel,  and  tuberculin  are  also  useful. 


=' Winkler:  Arch.   f.   Dermat.   ii.    Syphil..    Ixxvii,    3. 

'*  Morawitz:  Arch.   f.   Dermat.   u.   Syphil.,   1910.   cii,   121. 

"•^  Kren  and  Weidenfeld:  Arch.  f.  Dermat.  u.   Sj-phil.,  1909.  xclx,  79. 


CllAI'TKK   XI\'. 

L^■.MI'1I('.M.\'I^\. 

The  suhjoct  of  lyinplidid  and  mxcltiid  Itiiiidrs  has  loiiti-  confused 
not  only  clernuit()lo<rists.  but  clinicians  and  ]>atlu)l()^ists  as  well.  It 
seems  to  the  autlior.  liowever,  that  eertain  bi-oad  juinciples  aiv  now 
clear,  and  that  all  that  is  needed  is  to  study  the  details.  Adanii's^ 
classification  of  the  lynii)hoid  and  myeloid  diseases  is  ])ossil>ly  the 
most  satisfactory  one,  inasmuch  as  it  is  the  simplest  and  most  com- 
prehensive, although  he  does  not  follow  Tiirck-  in  dividin":  lympho- 
matoses into  leukemic  and  aleukemic,  and  pointing  out  that  cer- 
tain of  the  former  tyi>e  should  become  convei-ted  into  the  latter 
variety,  which  should   always  be  Ixn-ne   in    mind. 

The  followin<;  grou]i  of  diseases  is  associated  \\ith  cutaneous  tu- 
mors : 

Myelomata. 

^lultiple  myelomata. 

^Myeloid  leukemia. 

Chloroma. 
Lymphomata. 

Hodgkin's  disease. 

Lymjdiatic  leukemia. 

In  addition  to  these  jjeneral  diseases,  lymjihomatous  processes  may 
be  at  first  localized  in  the  skin  and  only  later  involve  the  other  blood- 
producing  organs.  The  primary  lymphatic  diseases  involving  the 
cutis  are  simple  lymphomata,  mycosis  fungoides,  and  lymphodermia 
perniciosa.  The  general  field  has  been  reviewed  by  the  author-'  in 
two  recent  articles,  one  in  association  with  Strobel,^  in  which  there 
is  a  full  discussion  of  the  problems  here  encountered  as  well  as  a 
complete  bil)liography. 

Multiple  Myelomata. — Two  cases  of  multiple  myelomata  showed 
cutaneous  manifestations.  The  ]iatient  of  Spiethoff's  showed  only 
an  erythrodermia,  but  Bloch's''  case  had  definite  tumors  of  5  cm. 
size. 


'Adami:  Principles  of  Patholog.v,  i. 

=  Tiirck:  Wien.   klin.   Wchnschr.,   1903.   x\  i,   1073. 

'Hazen:  Jour.  Cutan.   Dis.,   1911.   xxix,  521. 

<  Strobel  and  Hazen:  Jour.  Cutan.  Di.s.,   1011.   xxix,  117. 

J'Bloch:   Arch.   f.   Derniat.   u.   Sypliil..   lOlO.   xcix,   9. 

148 


I>^■\ll'll().\I.\•|■\.  149 

Myeloid  Leukemia.  Oiil\  tlncc  ciscs  ol'  myeloid  (sploiioinyolot?- 
cnoiisj  lciil<('iiii;i  sliowffi  liiiiiurs,  ;ill  lii)ii<i(i  iwo  or  llircc  otlioi'H  had 
vni'ious  I.Npcs  ol'  skill  lesions.  M  iiidciilx'i-^  li;i<l  uinlcr  ol>Hervation  fi 
woiiiJiii  ;i^C(l  10  willi  ;i  w ell  (|i\clo|)((|  myeloid  l(;ill<cmi;i  ;iiid  n  tii- 
moj'  oi'  the  1(;^'  (i  <-iii.  in  (li;iiiiclcr.  wliicli  \\;is  disliiiclly  due  to  the 
leukemia,  llollcslon  ;iihI  I''o.\''  rollowcil  ;i  |i;iti(;i)t  at?ed  58  with  an 
atypical  myeloid  Iciikcmi.i  ;in<l  in;iny  nodules  ovei'  the  body.  liruus- 
gaard  has  had  a  ease  in  which  Iheri;  were  infilli-atioiis  of  myehievtes 
in  the  subcutis. 

Chloroma.  In  all,  1eii  enses  of  ('liloi'(Miia  showed  ciilnneous  niani- 
fcstatioiis,  live  oi'  these  pjilieiils  luid  tumoi's  <ir  nodules,  usually  of  a 
greenish  color — namely,  the  cwses  oi:  llosenbhil  h,  i>)-am\vell,  Ilitsch- 
mann,  Paltauf,'  and  djicohjieiis.  The  nodules  were  usually  of  small 
size,  and  freely  movabh'  ui)ou  the  underlying  tissues.  The  most 
characteristic  thing  was  the  greenish  color. 

Hodgkin's  Disease. — Hodgkin's  disease  still  remains  a  fertile 
field  for  contention.  After  Reed's'*  work  appeai-ed  it  was  thought 
for  a  time  that  this  nudady  was  definitely  established,  and  that  it 
was  characterized  by  a  veiy  definite  histological  picture.  Cases  have, 
however,  been  reported  where  a  perfectly  typical  case  of  this  trouble 
has  developed  into  an  equally  typical  leukemia,  and  AVarthin'-'  has 
shown  that  certain  cases  have  the  pathology  of  simple  iymphomata, 
and  not  of  the  type  described  by  Reed.  In  this  disease  the  com- 
monest skin  manifestations  are  either  bronzing  or  pruritus,  but  def- 
inite nodules  or  tumors  may  develop. 

Lymphatic  Leukemia. — Lymphatic  leukemia  is  fairly  sharply  di- 
vided into  the  acute  and  chronic  forms,  although  thei-e  are.  of  course, 
transitional  stages  between  these  two  varieties. 

The  patients  suffering  from  acute  leukemia  frequently  showed 
purpuric  conditions  of  the  cutis,  a  number  of  other  cases  showed 
either  vesicles  or  urticaria,  but  seven  cases  showed  either  nodules 
or  small  tumors.  These  cases  are  described  in  the  author's  article 
as  well  as  in  the  more  recent  one  of  Nanta." 

Patients  suffering  from  the  chronic  form  of  lymphatic  leukemia 
not  infrequently  show  papules  or  vesicles  upon  the  skin,  but  nine 
cases  have  shown  either  tubercular  eruptions  or  fairly  large  tu- 
mors. As  a  rule,  these  lesions  did  not  ulcerate,  but  one  or  two  have 
done  so.     Thick  subcutaneous  infiltrations  were  not  uncommon:  these 


"  RoUeston  and  Fox:  Brit.   Jour.   Dermat.,   1909,   xxi,   377. 
"  Paltauf:  Mracek's   Handbuch   der   Hautkrankheiten,   Wien.,    1909,   v. 
sReed:  .Tohns  Hopkins  Hospital  Reports,   1902,  x. 
9\Varthin:  Osier's  Modern  Medicine.   Phila..   1908.   iv.   808. 
^"Nanta:  Ann.  de  Dermat.   et  de   Syphil.,   1912.   iii,   572,  639,  694. 


150  SKIX    CANCKR. 

occurred  usually  u^on  the  face,  and  often  <rave  tlio  j^aticiit  a  leonine 
expression,  snch  as  is  seen  in  leprosy. 

Lyraphoderniia  Perniciosa. — Lyniphodi-rmia  ixiuiciosa'^  is  un- 
doubtedl\'  a  li-ansiti(tn  stajre  between  leukemia  and  mycosis  fun- 
groides.  Tyjiic-al  cases  of  this  affection  show  an  intensely  itchy,  jjen- 
eralized  erythrodcnnia.  tiiat  i-csembles  a  "generalized  squamous  ec- 
zenui.  Latei-  cutaneous  and  subcutaneous  nodules  and  infiltrations 
develop,  that  may  or  may  not  ulcerate.  The  majority  of  these  cases 
show  a  ir''t'at  increase  in  the  white  blood  cells,  the  lymphocytes  be- 
in^'  the  most   numerous  cells. 

Mycosis  Fungoides. — ^Mycosis  funp:oides  is  one  of  the  most  in- 
teresting diseases  encountered  by  the  dermatologist.  According  to 
Crocker,^-  it  appears  in  three  different  forms — first,  Avhere  there  is 
an  antecedent  dennatitis.  usually  eczcmatous  in  apjiearancc  (Fig. 
58)  ;  second,  where  there  are  repeated  attacks  of  lymphangitis  lead- 
ing to  elei)hantiasis,  and  a  later  tumor  fonnation;  and  third.  Avhere 
many  tumors  suddenly  appear  without  an  antecedent  dermatitis,  the 
■"tumeurs  d'emblee"  of  the  French. 

This  disease  has  variously  been  classed  with  the  sareonuita.  the  in- 
fectious granulomata,  and  the  lymphomata.  In  a  careful  study  of 
the  condition,  Strobel  and  the  author  decided  that  the  malady  was 
not  a  true  sarcoma  for  the  following  i-easons:  that  the  cells  do  not 
infiltrate  or  metastasize  in  the  way  that  sarcoma  cells  do  because 
the  tumors  usually  develop  from  plaeciues  or  papules  (which  is  cer- 
tainly not  true  of  the  sarcomata)  ;  because  of  the  spontaneous  dis- 
appearance of  the  eruption  at  times;  and  because  of  the  sudden 
changes  that  might  take  place  in  it.  Nor  did  the  histological  pic- 
ture apiiear  to  be  the  same. 

They  felt  that  it  could  not  be  an  infectious  gi-anuloma  because  of 
the  richness  of  mitotic  figures  in  the  mycosis  cells;  because  the  rete 
■was  not  invaded  by  these  cells;  ])ecause  there  was  no  attempt  on 
the  part  of  the  body  to  wall  in  tliese  cells  ])y  an  iiilhuuinatory  ex- 
udate or  fibrous  tissue;  because  the  clinical  course  and  fatal  ter- 
mination of  the  disease  are  dift'erent  f i-om  those  of  the  granulomata ; 
because  there  is  no  history  of  contagion  or  any  especial  geographical 
center  for  the  trouble.  In  a  certain  number  of  cases  lesions  have 
been  described  in  the  bone  marrow  or  in  some  of  the  internal  lym- 
phatic structures,  never  elsewhere,  which  could  hardly  be  true  of  the 
granulomata. 

They  especially  felt  that  tiic  disease  should  be  classed  with  the  lym- 


"  Kaposi:  Diseases  of  tlie  Sl<in,  New  York.  1805. 

"  Croclter:  Diseases  of  tVie  Skin,  3d  ed.,  Piiila.,  1905. 


LVMI'IIO.VIA'I'A. 


151 


phoniata  l)Cf';uis('  of  the  Irisloloji'y  of  llic;  f^rowlbs,  the  lesions  eonsist- 
ing  of  lyrnplioid   eel  Is;   l)(!(';ui.s(!  Ilic  di.scjiHe    }i;ik    Uu;    Hurrie    {general 


Fig-.  58. — Mycosis  fungoides.     (Strobel  and  Hazen.— Courtesy  of  Journal  of  Cutaneous 

Diseases.) 

characteristics  as  many  others  of  the  lymphoid  and  myeloid  series 
— namely,  that  it  usually  occurs  in  males  past  49  years  of  age;  that 
the  averaee  duration  is  two  to  five  rears,  and  that  death  invariablv 


152  SKIN    CAXCKR. 

eoinos;  that  there  is  a  seeoiulary  anemia,  ami  that  the  lyiiii)h()ryte 
count  may  be  very  liiirh.  usually  showing:  an  increase  in  the  ];\v<iv 
mononuclear  cells;  jind  that  a  1_\  pical  h'ukt'mia  may  develoit  ;is  in 
the  case  reported  by  Pardee  and  Zeit  ;' '  and.  lastly,  that  thei-e  are 
direct  transitional  staires  lietween  tlu'  leukemias  and  m_\cosis  j'un- 
goidcs,  as  evidenceil  by  the  c(iiiditiiiiis  known  ;is  1>  iiiphodci'mia  pei'- 
niciosa.  Also,  it  should  be  remarked  that  the  same  remedies  have 
a  l)eneHcial  effect  here  as  in  the  otlier  mend)ers  of  the  frrouji — name- 
ly x-ray  and  arsenic — and  also  inteicunciit  in  feet  ions,  esjiecially  ery- 
siju'las.  They,  therefore,  feel  that  mycosis  fnui^oidcs  is  ;i  member 
of  the  j^rouj)  of  tliseases  usually  called  lymphomatous.  inid  that,  in 
the  sense  of  Tiirck.  it  is  an  aleukemic  l\iiiphomatosis,  that  may.  how- 
ever, beconu^  leukemic. 

Diagnosis. —  In  this  entire  <i'roiip  of  troubles  diaiuiiosis  should  not 
be  diflicult  if  it  is  i)o.ssible  to  stud\'  the  patient.  The  laboral(;ry 
methods  of  diaj^nosis  are  extremely  valuable,  for  the  dia«i:nosis  of 
leukemia  can  always  be  made  by  a  microscopical  examination  of  the 
blood,  if  it  be  borne  in  mind  that  a  victim  of  leukemia  nniy  have  an 
occasional  aleukemic  period.  ^Mycosis  fungoides  can  be  diagnosed  by 
the  study  of  a  section  of  the  skin.  Even  the  premyeotic  jiatches  have 
a  very  definite  hi.stology.  there  being  an  infiltration  of  the  subpapil- 
lary  portion  of  the  corium  with  lymphoid  and  an  occasional  cndo- 
thelioid  or  plasma  cell.  K^■(■u  the  suppo.scdly  normal  skin  may  show 
some  of  these  changes.  In  multiple  my(domata  \hvvv  is  a  large  (pian- 
tity  of  Benee-Jones  bodies  in  the  urine.  A  typical  case  of  liodg- 
kin's  disease  can  be  diagnosed  by  a  histological  study  of  a  small 
lymphatic  gland.  The  following  conditions  must  be  excluded;  lej)- 
rosy,  sarcomata,  sarcoids.  fil)roma  niolluscuni.  and  sinall  sulx-utaneous 
or  cutaneous  tumors  of  benign  coui'se.  such  as  iiiyomata  or  neuro- 
mata. 

Treatment. — The  treatment  is  eminently  inisatisfactory.  Ai-senic 
or  the  x-ray  may  alleviate  the  troul)le  for  a  time,  but  the  author 
is  not  satisfied  that  any  genuine  cases  belonging  to  this  grou]i  have 
been  cured,  altlioutih  thei'e  have  been  a  few  reports  in  the  litera- 
ture, lie  is  inclined  to  feel  that  these  cases  probably  belong  to  the 
Spieglei"-Fcndt  tyi)e  of  sarcoid. 

Benigii  Lymphomata.— Not  all  lyniphoinata,  however,  are  malig- 
nant, for  WinfickP^  has  recently  reported  a  remarkable  case  of  be- 
nign lyjnphomata  occurring  in  a  Avomnn  aged  To.  The  disease 
started  six  years  before  the  report  was  nuide  as  two  subcutaneous 


"  Pardoe  and  Zeit:  Jour.  Cutan.  Dis.,  1011,   xxix,  7. 
"Winileld:  Jour.  Cutan.  Dis.,   101.3,  xxxi,   245. 


LYMI'IHJ.MATA.  ]')'.j 

nodules  over  llu;  Icn.  iii;il;ir  proiiiiiictu'c,  that  wcrt;  ii)1ciiH(.'l\'  itfliy, 
J'oili  lllinoi'S  j^rcw  r;illicr  iMpidly  iiiilil  llicy  ;i11aili('(|  1  Ih;  <|i}iiii('1ci" 
ol'  aJ)(»il1  -!  cm.,  Itiil  llicy  did  iiol  coalesce,  nor  did  I  lie  skin  over  tlu-iii 
Tilcci'utc.  A  Jittle  later  siinilar  iiiiiiors  Ix'^an  1o  appear  (»n  oilier 
])()i'ii()ns  o:("  the  Paoq,  and  upon  Hie  body  and  linibs  as  well,  ('are)'iil 
l)hy.si('al  and  hihoralory  iii\  csl  i^al  ions  yieldeil  no  in  foiinal  ioji  as  tr> 
disease  in  any  ol:  the  iiilcrnal  oi-^aiis.  I  lislolo^ical  examination  of 
the  lesions  showed  a  Jiodule,  well  walled  in  and  not  invadinj^  the 
epidei'mis,  llie  cells  lieinj^'  of  a  small,  round  elm ivicter,  greatly  rc- 
seuil)]in^'  those  of  a  small  round-celled  sai'coma,  or  of  a  lympliosar- 
coiua;  they  were,  however,  later  decided  to  he  lyfdcal  jymphfjid  cells. 
Some  of  the  f^rowths  involuted   under  Ihc  adminisi I'ation  of  arsenic. 

Newbcrfi^er  reported  a  somewhat  similar  case  in.  1802,  Avhei'C  there 
were  likewise  small,  hai'd  groAvths  in  the  coriiim,  without  any  other 
symptoms. 

Ill  addition  to  the  articles  mentioned  a1)ove,  Arndt's''  sliouM  be 
read  by  any  one  who  is  interested. 


«  Arndt:  Jour.  Amer.   Med.  Assn.,   1914,   Ixiii,   1268. 


('H.\rTi:ij  x\'. 
i)iii'i:Ki:.\ri.\i.  DiAdXOSiS. 

Ill  (.lealinjr  with  cutaiu'ous  iu'ui»lasins.  there  are  two  essentials — 
first,  to  deeide  whether  the  new  growth  is  an  inflamniatory  one  or  a 
true  neoplasm,  and,  second,  to  decide  whether,  if  it  be  a  true  tu- 
mor, if  it  be  malignant  or  benign.  If  it  be  malignant,  it  is  neces- 
sary to  further  decide  whether  it  be  a  ])ri('kle-c('lU'(I  tumor,  or  a 
basal-celled  groAvth,  or  if  it  be  a  sarcoma. 

In  order  to  decide  this  question  accurately,  it  is  often  necessary 
to  ai^proach  the  problem  in  three  different  ways — first,  the  clinical 
aspects  of  the  new  growth ;  second,  its  gross  pathology  as  seen  by 
the  naked  eye;  and  third,  its  hi.stological  .structure  as  seen  by  the 
microscope.  The  better  the  pathologist  that  the  operator  is  the  more 
frequently  will  he  be  able  to  make  a  diagnosis  from  the  first  two 
of  these  criteria,  and  hence  the  more  promptly  will  the  patient  be 
dealt  with  and  the  necessity  for  second  operations  lessened. 

History.— The  first  point  is  to  obtain  a  careful  history  from  the 
l)atieut.  The  age  must  always  be  noted.  It  is  rare  for  malignant 
epithelial  tumors  to  arise  before  the  age  of  thirty,  except  in  the 
condition  know^n  as  xeroderma  pigmentosum.  Nor  does  a  mole  often 
become  malignant  under  the  age  of  forty.  Likewise  sarcomata  of 
the  skin  are  not  common  in  the  young. 

The  occupation  of  the  jiatient  must  always  be  noted,  for  malig- 
nant tumors  of  the  basal-celled  variety  not  infrequently  develop  in 
those  wlio  have  l)een  much  exposed  to  actinic  rays,  whether  produced 
by  the  sun  or  by  the  riintgen  tube.  Those  who  are  engaged  in  the 
manufacture  of  paraffin  and  tar  arc  especially  liable  to  cutaneous 
cancer. 

Fui-thermore,  it  should  be  decided  whether  there  was  a  precan- 
cerous dermatosis  antedating  the  new  growth.  From  the  common 
senile  warts  we  usually  find  a  basal-celled  carcinomata  resulting; 
from  an  x-ray  burn  a  prickle-celled  neoplasm  is  much  more  likely 
to  arise.  If  the  growth  be  from  a  pigmented  mole,  we  are  usually 
dealing  with  either  a  nevocarcinoma  or  multiple  melanomata,  both 
very  malignant.  In  the  scars  of  old  wounds  prickle-celled  growths 
or  sarcomata  may  arise,  while  from  vascular  nevi  we  practically  find 
only  sarcomata. 

154 


DIKFKKIlNI'IAIi    DIACiXOSIS.  155 

The  duration  ol"  syiiiploins  Is  lil<<'\visc  of  s|)ccl;il  irrii-)ort,  for  the 
more  malis'iifiiil,  1li<'  tiiinor  the  more  iMpIdly  il  <;r()\\s.  A  basal -cdlofl 
tumor  may  g'r()\v  iiuirc  iMpidly  lli;iii  ;i  prieklc-collfd  one,  hut  this  is 
I'arc. 

With  a  deeply  seated  Jieophism  il  is  always  best  to  exclude  syph- 
ilis, and,  to  deeide  on  this  })oiiil,  lln:  y)atient's  word  should  never 
be  accepted,  but  tiie  (liai?ii()sis  coiiCinncd  b\  1he  various  laboratory 
tests,  rememberjii<>'  that  botli  the  Wassei'inaiiii  and  luctin  reactions 
may  be  negative  in  lonj^  standing  cases  of  this  malady,  and  hence 
not  putting  too  iimch  reliance  in  them.  At  times  a  superficial  }^im- 
ma  before  idceration  may  almost  exactly  i-esemble  a  norlnlar-  or  rollcrl- 
edge  rodent  ulcer. 

The  symptoms  of  onset  must  be  noted,  and  what  was  the  first,  pain, 
itching,  serous  discharge  denoting  superficial  ulceration,  or  the  pres- 
ence of  a  nodule.  It  must  always  be  remembered  that  pain  is  com- 
paratively I'are  in  skin  tumors,  whether  malignant  or  benign. 

The  later  symptoms  must  be  carefully  asked  for  in  order  to  de- 
termine as  to  the  possibility  of  metastases.  While  cachexia  is  ex- 
tremely rare  in  skin  cancers,  yet  metastases  from  them  may  cause 
these  symptoms.  In  large  ulcerating  growths  the  a1)sorption  of  toxins 
from  secondary  bacterial  infection  may  cause  a  picture  of  cachexia. 

The  local  signs  and  symptoms  are  much  more  important  than  the 
general ;  we  must  always  try  to  find  out  how  rapidly  the  tumor  grew 
when  first  observed,  and  how  rapidly  it  has  grown  within  the  past 
few  weeks. 

Examination. — In  the  examination  of  the  growth,  certain  facts 
must  be  observed.  First,  we  should  note  the  relation  of  the  tumor 
to  the  skin,  for  certain  tumors  arising  from  the  appendages  may  not 
at  first  be  adherent  to  the  epidermis,  while  the  basal-  and  prickle- 
celled  growths  almost  invariably  are  attached  to  the  skin  from  the 
incipiency.  On  inspection  we  must  note  the  size  of  the  growth — 
whether  it  is  exuberant  or  Avhether  it  has  formed  a  deep  ulcer.  The 
character  of  the  surface  must  be  observed,  for  prickle-celled  neo- 
plasms usually  have  a  very  rough  and  irregular  surface.  The  amount 
and  character  of  the  discharge  is  important,  for  absorption  may 
cause  many  general  symptoms.  jMetastatic  growth,  either  in  the  vi- 
cinity or  in  the  glands,  must  be  looked  for.  And  especially  impor- 
tant is  the  situation  of  the  tumor,  for  growths  on  the  face  except 
the  lips  are  usually  comparatively  benign,  while  those  upon  the  ex- 
tremities are  usually  A^ery  malignant.  Likewise,  if  there  be  mul- 
tiple growths,  they  are  probably  of  a  basal-ceUed  origin,  if  not  ex- 
amples of  multiple  sarcomata. 


156  SKIN    OANCKK. 

On  palpation  the  i-liarat'tor  ul  llu>  induration  is  esitocially  impor- 
tant, for  the  carcinoiiiata  in\arial)l\'  liavr  an  extroinoly  hard  cdfre. 
while  in  iiithmimatui-y  lesions  tliis  is  lackiiiir  as  a  .ni'iieral  rule.  The 
(h'pth  ot'  the  induration  is  liki-wisi'  iini)oi-tant,  for  in  the  malitrnant 
•rrowths  this  it>  usually  eonsiderahh'.  It  must  always  be  boi-ne  in 
mind  that  there  may  hi'  an  inllannn;itoi'\"  indui'ation  that  may  sim- 
ulate a  eaneerous  one.  The  nei^hhorinj;  ^dands  shouhl  always  l)e 
])ali>ated.  aiiaiu  rememherinir  that  an  eidarjrement  of  them  can  de- 
note an   inlhinniiatorx'  condition. 

Gross  Pathology.-  After  a  tumor  is  excised,  it  sliiiuld  be  sec- 
tioned at  once  in  order  to  determine  its  variety  and  the  depth  of  its 
iniiltration.  \n  the  s(iuamous-celled  cancers  the  inliltration  is  com- 
paratively deep  and  wide.  Tliese  <::i-owths  also  sliow  ;i  chai-acteristic 
picture  on  section,  for  there  can  be  observed  fine  uliite  lines,  about 
the  size  of  fine  sewin«?  cotton,  i-adiatin^  downward  from  them,  a 
condition  totally  lacking  in  the  inflammatory  conditions,  and  usual- 
ly not  marked  in  the  ba.sal-celled  gi-owths.  wliere  the  cancerous  al- 
veoli arc  smaller. 

In  obtaining  material  fen-  microscopic  study,  ceiiain  ]irecautions 
must  always  be  observed.  Among  the  majority  of  surgeons  there  is 
a  strong  feeling  that  it  is  freiiuently  dangerous  to  excise  a  portion 
of  a  tumor  for  examination  if  that  tumor  be  of  a  nudignant  na- 
ture, for  incision  leaves  a  number  of  gaping  l)lood  vessels  and 
lymi)hatics  into  which  cancer  cells  might  e.scai)e  and  thus  cause 
metastases.  At  the  same  time,  it  is  occasionally  essential  to  examine 
such  tissue,  so  the  following  scheme  is  usually  adopted.  If  the  tu- 
mor be  upon  the  lip.  (»!■  upon  a  part  where  it  is  })ossible  to  temporar- 
ily constrict  the  blood  vessels  by  pressure,  an  assistant  does  this  with 
his  fingci"s,  then  a  piece  is  excised  under  local  anesthesia  from  the 
edge  of  the  gi-owth.  taking  care  to  include  a  small  portion  of  ap- 
parently normal  skin,  in  order  to  determine  th(>  iidiltrative  ]>owers 
of  the  cancer  cells,  and  the  wound  is  then  thoroughly  cauterized  with 
either  the  actual  cautery  or  a  strong  chemical  one. 

In  very  eai'ly  cases  it  is  often  im])ossit)l(^  to  detei'iniiu^  from  a 
clinical  examination  or  from  the  naked  eye  ai)])earance  of  the  tumor 
to  what  vai-iety  it  l)elongs,  and  then  the  whole  growth  may  be  re- 
moved and  sections  made  from   it. 

Microscopic  Pathology. — The  tissue  can  be  presei-ved  in  any  of 
tlic  accei>ted  lixing  agents,  although  7)0  ])ercent  alcohol  oi-  ]0  per- 
cent formalin  will  usually  suffice,  and  is  then  fixed.  l)l()cked.  cut. 
stained,  and  mounted  in  the  usual  manner.  Probably,  for  routine 
examination,  no  stain  is  l)et1er  than  hematoxvlin  and  eosin.     A  com- 


I)II''|'i;k,i:\ti Ai-  ui\(;s(y<\<. 


157 


potent  Tni(M'()Sf()i)is1  cnii  iisiuilly  IImii  di.ij^iiosc  IIk;  r-orulition  wilhoiil 
trouble,  fill  lion  j^li  one  should  be  sclictcil  wlut  knows  tin;  (Wfi'cvcwcc 
between  tlic  b;isiib  ;im(1  prickle  (M'llcd  vni'idics.  in  fcrtain  ^jrowths 
orif^'in;itin<4-  from  the  {^'landiibir  ;ipi)cnd;i<ics  of  llic  skin  i1  is  some- 
times vcM'.v  diriicnJI  to  decide  whellief  llie  growths  ;ire  nnilit^narit, 
and  here  Jl  is  occ;isi(»n;dly  necessary  1o  \\;\\c  llie  sei-viees  of  an  ex- 
pert, and  then  opinions  may  dilTer.  I'suidly.  however,  the  qiiestioii 
ean  be  deeided  by  ;iny  one  who  h;is  li;id  ;i  broad  ])atholof?ieal  train- 
injj:.  It  must  alwa\s  be  borne  in  mind  by  the  novice  that  inflamma- 
loi'v    conditions    cjin    cause    a    i>;rvi\\    overj^rowl  li    of    e[»itheli;d    tissue 


Fig.  59. — In  certain  chronic  infections  of  the  skin,  notably  tuberculosis,  of  which 
this  is  an  example,  there  is  a  marked  hypertrophy  of  the  epidermis,  which 
may  render  it  difficult  to  distinguish  from  cancer.  Usually,  however,  the  re- 
lationship between  the  basal-  and  spino-cells  is  not  altered.  (Author's  collec- 
tion.) 

(Fig.  59),  but  this  should  not  be  mistaken  for  malignant  hyper- 
trophy, for  the  papillary  structure  is  better  retained;  the  cells  of 
the  rete  are  normal  in  arrangement  and  in  their  relationship  to  one 
another,  even  though  they  be  greatly  increased  in  number.  Xor  is 
the  basement  membrane  broken  through. 

The  microscopic  differences  between  the  scpiamous-  and  basal-celled 
types  of  cancer  has  already  been  fully  discussed  in  the  chapters 
dealing  with  those  subjects. 


158 


SKIN    CANCKR. 


In  ireneral.  it  may  be  said  that  four  classes  of  lesions  nuist  be 
differentiated  from  the  various  types  of  cutaneous  cancer — first,  those 
lesions  causing  nodules,  as  tlie  benifzn  tumors,  cysts  of  various  kinds. 
chancres,  and  fjummata;  second,  the  ulceivitive  variety  of  lesions,  as 
luinis  vuljjaris,  sypliilis  in  the  ])rimary  or  tertiary  stage,  tramnatie 
ulcers,  and  certain  of  the  rare  ^M-anuloinata.  as  sporotrichosis;  third, 
the  pajullary  lesions,  such  as  a  more  or  less  diffuse  pai>illomatosis 
secondary  to  irritating  disciiarges,  exuberant  granulation  tissue, 
granulomata  pyogenicum,  tuberculosis  verrucosis,  blastomycosis,  and 
very  rarely  framboesiform  syphilis;  fourth,  lesions  causing  scarring, 
as  lupus  vulgaris,  syjihilis.  lui)us  ci-Ntliematosis.  and  mor])hea. 


Fig.   60. — Chancre  of   the   chin.      (Gilchrist'.s   collection.) 


1.  Nodular  Lesions. — There  are,  of  course,  many  varieties  of 
solitaiy  tumors  of  the  skin;  there  are  found  fibroids,  fatty  tumors, 
lymphoid  tumors,  neoplasms  originating  from  the  l)lood  or  lymph 
vessels,  endotheliomata,  wens,  dermoid  tumors,  sarcoids  of  various 
varieties,  and  a  number  of  inflammatory  conditions,  of  -which  chancre 
and  gummata  are  the  more  prominent.  With  the  exception  of  the 
last  two  just  named,  the  diagnosis  is  usually  easy,  for  we  find  that 
nearly  all  of  these  growths  present  themselves  as  definitely  encap- 
sulated, slowly  growing  tumors,  that  only  rarely  ulcerate  through 
the  skin,  and  then  only  after  they  have  existed  for  many  years.  All 
of  them  lack  the  stony  hardness  at  the  edge  that  is  characteristic 
of  the  carcinomata,  and  akso  the  firm  attachments  to  the  underlying 


DIPFERr:N'l'IAL    I)IA(;XOSIS. 


ir/j 


and  overlying  strufliifcs.  S;n'f'oinata  nuiy  morn  rioarly  rosfinhlt; 
these  {growths,  for  at  first  tlicy  iwv,  often  found  to  he  prf;tty  definite- 
ly cncapsnlatecl,  nnd   Iicik-c   freely   ino\;il)Ie. 

Chancre. — At  times  it  is  extremely  difficult  to  make  a  differential 
di;i,f?iu)sis  betAveen  a  chancre  and  a  raxjidly  {^rowing  nodular  cancer 
(Fififs.  GO,  61),  for  both  have  the  same  cartilaginous  resistance,  and 
ulceration  often  takes  jjlace  in  the  center  of  each  in  about  the  same 
way.  The  observance  of  a  number  of  facts  will,  hoAvcver,  aid  in 
making  a  diagnosis.  In  llie  first  place,  the  age  of  the  patient  is  a 
great  factor,  for  cancer  is  infrequent  in  the  young,  while  chancre 
usually  does  not  occur  in  the  old,  although  it  may,   of  course,  do 


Fig.   61. — Chancre  of  the  lip  of  one  month's  duration.      (Author's   collection.) 


SO.  Second,  the  location  of  the  growth  is  of  some  aid.  for  chancres 
are  rare  except  upon  the  penis,  lips,  or  fingers,  although  they  may. 
of  course,  occur  upon  any  part  of  the  body.  Cancer  is  rather  rare 
upon  the  upper  lip,  and  practically  never  occurs  upon  either  lip 
in  a  woman.  Third,  the  growth  of  a  chancre  is  usually  very  much 
more  rapid  than  that  of  a  cancer,  a  diameter  of  2  cm.  being  not  in- 
frequently obtained  in  less  than  two  weeks;  and  fourth,  the  neigh- 
boring glands  usually  swell  within  a  month  after  the  initial  appear- 
ance of  a  specific  lesion,  which  is  not  found  in  cancer.  In  cases  of 
doubt,  the  spirochete  should  be  searched  for  with  the  dark  field  il- 
luminator; this  instrument  is  much  more  satisfactory  than  the  ex- 
amination of  stained  specimens.     AVhere  none  of  these  methods  are 


IGO 


SKIN'    CAXCKR. 


availaMo.    salvarsan    slioiild   l)e    adiuiuistoi-ctl    intravoiioiisly,    and.    if 
tho  irrowth  ilisapi>oars.  it   was  uiitldulilrtUy  luolit-. 

Gumma.^ — Karoly  a  i;uiiiiiia  iiia\-  i)iH'siMit  syiii])1()iiis  llial  make  it 
pi-actically  iinj^ossiblo  to  diffoiriitiato  tioiii  caiiciT.  Tlu'  autlior  has 
recently  seen  two  cases  ot  tumors  ui)on  the  nose,  hotli  oecurrin^  in 
people  past  40,  wlm  presented  no  other  evidences  of  syphilis  (Fig. 
G2).  In  both  of  these  eases  there  was  a  raised,  extremely  hard  edge, 
with  dilated  blood  ve.ssels.  no  ulceration  for  a  number  of  months,  and 
no  marked  inthunmation  i)resent.  Hoth  cases  were  considered  to  l)e 
cancerous.  Imt  in  l)i>tli  cases  sect  inns  slmwcd  ;i  typically  <iuniiiiatotis 
structure,  and  l»oth  cleared  up  uiulci'  sahaisan.  As  a  ^icneral  rule, 
a  n:umma  is  inMammatoix  and  soon  breaks  down,  forming  a  punched- 
(tut  ulcer  that  has  a  soft  edge  (Fig.  63).  There  are  three  ways  of 
iiiakinjr  a   differential   diauiiosis  in   doubtful    cases — first   and    surest. 


Fig.    62. — Gumma  of   the   no.'^e.    with   a   hard-rolled    edge   .simulating    carcinoma. 

(Author's  collection.) 


by  taking  a  piece  of  tissue  for  examination  ;  second,  by  finding  other 
signs  of  .syphilis,  either  clinically  or  b\'  laboratoiy  methods;  and 
last,  by  the  so-called  therapeutic  test — namely,  tlie  intensive  admin- 
istration  of  antisy]>hilitic  treatment. 

2.  Ulcerative  Lesions. — The  ulcei-itive  lesions  aie  usually  easy 
to  differentiate,  for  tlicy  too  lack  many  of  the  ])hysical  clmracteristics 
of  cancer — namely,  the  hiii-d  edge,  with  the  pearly  nodules  therein. 

Lupus  Vulgaris. — Lupus  vulgaris  (Fig.  64)  usually  originates  in 
tht-  young;  it  is  very  rare  to  find  a  case  starting  in  a  })atient  over 
20  years  of  age.  The  growth  of  the  ulcer  is  slow,  although  not 
slower  than  that  of  a  rodent  ulcer.     One  characteristic  of  a  tuber- 


i)iKi-"i';ui';N'riAi.  I)IA(;nosis. 


161 


culoiis  ii](*(!r  is  llic  ovci'liJiiij^iii;^'  cd^c  of  skin,  tin  \i\ccr  iiul  hcih^j 
cleanly  putu^licd  out  (  ^''i^^  (ir)).  In  sdinc  instances  lif;ilint.'  may  take 
j)laee  in  tho  center,  Icjiviny'  ;i  ('i)ni|);ii-;it  i\cly  sii|)(rfici;il  soft  HCar. 
A  section  t;iken  from  tlie  cd^c  of  ;i  |i;it<-li  of  Iii|his  will  show  that 
the  condition  is  ;in  in(l;iiiiin;itoi'y  one,  ;ind  the  prc.-seiice  of  {fiant,  but 
more  especially  endolhelioid,  cells  may  !»<■  <li;ii;ictcristic.  The  cd*<e 
is  nevei-  stony  hjii-d.  It  is  suvprisinj?  to  see  how  often  rodent  ulcers 
are  dia^'nosed  ;is  lupus,  for  in  ve;dity  there  is  no  excnse  for  this  mis- 
take. 

Chancre. — A  clumcre    r;irel\'   ulccnilcs   ex1cnsi\<'l\-   enouuli    1o   he 


Fig.    63. — Gummatous   lesion   of   the    lip.      No    induration   at   edges. 
(Author's    collection.) 


mistaken  for  an  ulcerated  cancer ;  it  is  only  in  the  nodular  type  that 
trouble  may  arise. 

Syphilis. — Syphilitic  ulcerations,  especially  of  the  serpisfinous 
type,  where  growth  is  slow  at  times,  can  be  mistaken  for  an  extreme- 
ly superficial  rodent  ulcer,  but  the  condition  of  the  edge  should  serve 
to  differentiate  between  them,  for  the  syphilitic  lesion  does  not  have 
the  great  hardness  and  comparatively  deep  infiltration  of  the  can- 
cerous one.  A  biopsy  Avould  decide  the  question  beyond  all  shadow 
of  doubt,  for  syphilis,  in  its  histological  aspects,  does  not  simulate 
cancer. 

Traumatic  Ulcers. — Traumatic  ulcers  lack  the  hardness  of  can- 


1G2 


SKIN    CANCKR. 


ccr.  Jilthouirh  tlu>y  may  l)eoonio  c-ancoi-oiis  untlor  very  oxcoptional  oir- 
cunistam-cs.  A  i-a])id  .i;rowth  of  jtaiiilloiuatoiis  tissue  rosombliii';  a 
dirty  jjranulation  tissue,  but  iimiv  aiu'inic  and  less  vascular,  would 
inako  one  very  suspicious  of  beginning  malignant  change.  The  .same 
hoMs  true  of  varicose  ulcers. 

Sporotrichosis. — The  lesions  of  sporotrichosis^  arc  usuall\'   nud- 
tiple,  and  follow   the  cour.se  of  tlu^  lym])hatic  ves.sels;    in    addition 


Fig.    64. — Lupus    vulgaris,    .showing    spontaneous    lu-aling    in    center, 
duration.      (Author's   colleition.) 


K\n]a     years' 


the  cau.sal  oi'gauism  can  be  demonstrated.  Mosl  of  the  otlier  gran- 
ulomatous affections  arc  acfiuii'cd  in  tro])ical  or  .semitrojdcal  coun- 
tries, and  in  persons  Avho  have  lived  in  them  such  conditions  must 
be  excluded,  which  is  u.sually  not  difficult,  for  the  condition  of  the 
edge  of  the  growth  is  a  sure  sign  to  guide  one. 

3.     Papillary  Lesions. — ^[ost  of  the  papillary  lesions  should  not 


"Hyde  and  Davis:  Jour.  Cutan.   Dis.,   lOlO,   xx\iii.  :',2\ 


1)||'|'i;i;i:n'ii  \ii  diagnosis. 


163 


(•juiKc.   trouble,    l)iii   (K'cjisioiKilly    IIk'V    do,    cspccinlls-    to   oiio    who   has 
jioi  seen.  iii;iiiy  of  I  liciii. 

Diffuse  Papillomatosis.  Oik;  coiidilioii  11i;i1  is  uol  ircuc rally  rec- 
ognized oven  ])y  cxpcriciic'cd  cliiiicians  is  tlic  diffuse  papillomatosis 
of  the  skin  caused  by  an  iri'itatiu*^  diseliarj^c.  Fig.  GO  shows  a  very 
extreme  form  of  it,  but  it  is  often  seem  in  milder  forms,  especially 
around  chronic  leg  nieers  in  wliieli  thei-e  has  been  mufh  weeping. 
The  common  venereal  wai-ts  arc  the  most  familiar  examples  of  this 
condition;  other  illnsti-ations  arc  the  so-called  dermatitis  vegetans 
and  pemphigus  vegetans,  in  both  of  whieh  eonditions  a  discharge  has 
set  up  a  pi'olifcration  of  epithelial  tissue. 


Fig.  65. — Tuberculous  ulceration.      (Randolph's  case.) 


Exuberant  Granulation. — Ordinary  exuberant  granulation  tissue 
is  occasionally  mistaken,  but  should  not  be,  for  it  is  of  a  different 
color,  lacking  the  dirty-white  splotched  appearance  that  cancerous 
tissue  assumes,  and  also  totally  lacking  the  induration. 

Granuloma  Pyogenicum. — The  condition  known  as  granuloma 
pyogenicum-  is  simply  an  excess  of  granulation  tissue  caused  by  an 
infecting  microorganism,  and  might  be  confused  with  sarcoma,  but 


=  WMle:  Jour.  Cutan.  Dis.,  1910.  xxviii.   663. 


1G4 


SKIN    CANCRR. 


lU'viT  with  farc'iiionia ;  tho  rxtrcMiic  toiulcnicss  and  lack  of  indura- 
tion in  the  irniuth  shcuild  sitvo  to  diflVrontiato  it  from  cithor  con- 
dition. 


Fig.   66. — Diffu.'se  papillomato.sis  of  skin.      (Author's   collection.) 


Tuberculosis  Verrucosa  Cutis. — Tulierculosis  vci-i-iu'osa  cutis  (f'iff. 
GTj  could  be  nii.stakeu  only  by  a  tyi'o.  foi-,  as  a  general  rule,  the 
surface  epithelium  is  almost  intact,  the  lesions  lack  dej)th  and  in- 
duration, and  are  almost  invarial)ly  multii)le. 


i)ii'i'')';Ki;N'iiAL  1)IA<;n()Sis. 


k;.") 


Blastomycosis. —  P>];iKtornycoHiH''  (V]^.  GH)  uKually  chuhch  a  truo 
j);ij)ill()iiiiil()ii.s  ovcr^i'owlli  of  the,  skin;  IicIvvj-cm  IFic  \cyv\icosc  pro- 
jectioiiH  }U'(!  iniiiutc!  abscesses  eontirniiii^-  pus,  in  wliidi  il  is  usually 
easy  to  dernoiistratc  the  eausativ(!  or^'anism.  The  eolor  is  often  ])Ur- 
I)liKh,  and  ther(^  is  a,  laek  of  (\vv.\)  infill  rat  ion,  the  eonditiori  feelint,' 
S0f?{?y,  I'Hi-her  than  indurated.  'I'lie  lesions  are  nsnally  hiulti|»le,  and 
there  may  l)e  a  number  of  minute  abscesses  in  the  skin  beyond  the 
limits  of"  the  lesions  i)ro])er. 


Fig.    67. — Tuberculosis  verrucosa   cutis.      (Author's    collection.) 


Yaws  and  Syphilis. — In  either  yaAvs  or  framhesiform  syphilis 
the  lesions  are  invariably  multiple  and  laek  deep  induration:  they 
are  apt  to  be  most  pronounced  on  the  face  and  around  the  genitalia 
or  axillae. 

4.  Scar-forming  Lesions. — As  already  pointed  out,  cancer  may 
heal  spontaneously  in  the  center,  and  have  only  a  slight  amount 


'  Stelwagon:  Diseases  of  the  SKin,   7th   ed..  Phila.,  1914. 


166 


SKl.N    CA.\"Ci:U. 


of  ulceration  at  the  cdj^cs;  the  most  extrenu'  exaniiile  of  this  ty])C 
is  the  luorpliea-like  epithelioma.  Tliere  are  a  number  of  other  (mui- 
ditions  Avhieh  likewise  eause  scarring',  perhaps  with  veiy  little  ul- 
ceration, and  they  nuist  be  diagnosed  from  this  variety  of  cancer. 

Lupus  Vulgaris. — Lui)us  vuljrari.s  will  often  heal  in  the  center, 
and  show  only  a  ('()ini)aratively  narrow  zone  of  ulceration  at  the 
margin.  The  overhanging  edges  of  skin  and  tlic  lack  of  deep  in- 
duration would  serve  to  distingui.sh  this  condition  from  cancer,  even 
if  the  age  of  the  patient  did  not,  for  lupus  is  extremely  rare  except 
in  childhood. 

Syphilis. — The  lesions  of  syphilis  spread  very  much  more  rapidly 
tluui  do  those  of  superficial  cancer,  and  the  ulceration  is  usually 
clean  and  punched  out  in  appearance,  besides  lacking  hardness. 


Fig.    68. — Blastomyccsis.      (Author's   collection.) 


Lupus  Erythematosus. — Lupus  erythematosus  causes  scarring 
without  ulceration;  the  surface  of  the  skin  is  covered  by  closely  ad- 
herent white  scales,  and  the  follicles  gape  widely;  the  color  is  pink- 
ish. The  lesions  are  usually  multiple,  have  a  great  tendency  to  be 
symmetrical  upon  the  face,  especially  the  nose,  cheeks,  and  around 
the  ears.  This  condition  may  be  confused  with  syphilis,  but  not 
of  cancer. 

Morphea. — ^MOriihea  may  siniulalc  one  ty])('  of  caiu'ci-,  already 
fully  described  under  the  heading  of  morphca-like  epithelioma  in  the 
chapter  on  the  basal-celled  cancers.  As  pointed  out  at  that  time, 
the  presence  of  ulceration  or  of  a  i-aised  firm  edge  should  suffice 
to  differentiate  between   Ihoin.     TJnrclv  the  caiu-ci-  ot   niirassc  may 


diI''1''i;ki;x\'1'i.\l  diaoxosis.  KJT 

rescnil)lc  a  Hr-lcrodcnna,  but  cxjiiniiKilioti  of  llir;  bi'nasl  will  iihii;i1I>' 
clear  up  tlie  dijij^iiosis. 

Serodiag'nostic  Methods. — Jt  is  iinpossihlf  to  concliKb;  a  chap- 
ter on  the  diagnosis  of  cancer  without  a  word  or  two  of  reference 
to  the  attempts  at  laboratory  diagnosis  l)y  iiuians  of  utilizing  the 
changes  in  the  bodily  cells  and  fluids  that  have  takc^n  jjlaee  because 
of  cancer.  The  majority  of  these  tests  are  satisfactorily  described 
in  the  third  edition  of  Miillci-'s  "Scrodi;ignostic  Methods,"  tivins- 
lated  by  Whitman.' 

The  reaction  of  Freund  and  Kaminer^  depends  on  the  observa- 
tion that  the  blood  scrum  of  normal  individuals  has  the  power  to 
dissolve  cancer  cells,  the  scrum  of  cancer  patients  lacking  this  power 
— indeed  having  the  power  to  inhibit  the  desti-uclion  of  such  cells 
by  normal  serum. 

Von  Dungern"  has  attemi)ted  tlie  diagnosis  by  the  well-kno"vvn 
principle  of  deviation  of  the  complement,  l)ut  in  tlie  liands  of  others 
the  I'esults  have  not  been  satisfactory. 

Kraus,  Graff,  and  Ranzi^  have  attempted  to  diagnose  cancer  by 
means  of  the  cobra  venom  method,  which  depends  on  the  principle 
that  in  certain  conditions  human  blood  serum  possesses  the  ability 
to  activate  the  hemolysis  of  horse's  red  blood  cells  by  cobra  venom. 

Marcus's^  modification  of  the  method  of  Miiller  and  Joehmann^ 
depends  on  the  fact  that  the  digestive  power  of  trypsin  is  neutral- 
ized by  a  certain  amount  of  serum  or  blood.  The  method  of  Berg- 
mann  and  Meyer^°  depends  on  the  same  principle. 

The  meiostagmin  reaction,  as  practiced  by  Ascoli  and  Izar^^  and 
others  depends  on  the  principle  that,  when  diluted  blood  serum  of 
patients  is  mixed  with  a  homologous  antigen  and  heated,  there  oc- 
curs a  specific  lowering  of  the  surface  tension. 

Elsberg,  Neuhof,  and  Geist^-  have  described  a  skin  reaction  for 
carcinoma  that  has  been  investigated  in  this  country  by  Lisser  and 
Bloomfield^^  at  the  Johns  Hopkins  Hospital.  The  injection  of  5 
minims  of  a  20  percent  suspension  of  washed  human  red  blood  cells 


*  Miiller:  Serodiagnostic  Methods.   3d  ed.    (translated  by  "SVhitman).   Phila.,   1913. 

5  Freund  and  Kaminer:  Wien.  kiln.  Wchnschr.,  1911,  xxiv,  1759. 

6  Von  Dungern:  :\Iunch.   med.  Wchnschr.,   1912.   lix,   65,  1098,  2854. 
•Kraus,  Graff,  and  Ranzi:  Wien.  klin.  Wchnschr.,  1911,  No.  28. 

s  Marcus:  Berl.  klin.   Wchnschr.,   1909,   No.   4. 

°  Miiller  and  Jochmann:  Miinch.  med.  Wchnschr.,  1909,  Nos.  29,  31. 
"  Bergmann  and  Meyer:  Berl.  klin.  Wchnschr.,  1908,  No.  37. 

"Ascoli  and  Izar:  Miinch.  med.  Wchnschr.,  1910,   Ivii,  62,  182,   392.  403,   842,   1170, 
2129. 

"  Elsborg,  Neuhof,  and  Geist:  Amer.   Jour.  Med.   Sc,   1910. 

^3  Lisser  and  Bloomfield:  Bull.  Johns  Hopkins  Hospital,  1912,  xxiii,  356. 


168 


SKIN    t\.\(i;K. 


just  hc..u.;,tl.  thr  skin  is  l-oll..w,..l  l.y  a  ..hara.-f.Tisli.  n.H-tion  in  nn.nv 
cancer  i)atioiits. 

Kxvn  nuMv  ro-ently  it   has  h.vn  ,.ropos...l  to  us.  a  nM,.lili..at inn  of 
TiH'  AbilerhaI«lon  reaction   for  pref^nancy.'^ 

Fortunately,  lumever.   in  .-an.-er  of  the  skin   it    is  not  neeessarv  i.. 
depen.l  ,.n  sueh  n.etho.ls.   f..,-  ,h,.  .lia.Mu.sis  ran   nsnallv  be  ma.i;.  l,v 
mspect.on.   and.    if   not.    hy    Uu-   ..xaniinalion   of  tissur."   whi.-h    is   -,1 
ways   readily  ohtaincd. 


Editorial:  .I,,ur.    Arm-r.    M.-d.   A.>..mi..   v.n:i.  l.xi.    i 


461. 


CTT AFTER  XVi. 
PROGNOSIS. 

Thv  i)r()<fii()sis  in  ciiiiccr  of  1  he  skin  depends  on  severjil  f;ietoi-s — 
fii'st,  the  type  of  cancer;  second,  the  sla^^e  of  1lie  <liscasc;  third,  Ihe 
situation  of  the  tumor;  and  hisl,  1he  sl<ill  of  1li<'  f.hysician  who  has 
charge  of  the  case. 

Precancerous  Conditions.-  I n  llie  majoiilv  ol  iiishmces  the  va- 
I'ious  so-called  precancerous  conditions  and  benign  luinors  do  not  be- 
come malignant,  with  a  few  exceptions.  Xerodernia  pitiineiitosum  al- 
ways becomes  malignant,  and  ciilaneons  horns  ai'c  very  apt  to  do 
so.  Probably  from  5  to  10  i)erccnt  of  all  senile  keratoses,  especially 
when  situated  upon  the  face,  develop  into  cancei-s.  AVhen  one  con- 
siders the  enormous  numl)er  of  pigmented  moles  that  exist,  it  is  evi- 
dent that  a  very  small  percentage  of  them  cause  trouble,  except  Avhcn 
subject  to  chronic  irritation,  and  then  the  percentage  cannot  be  very 
high.  The  so-called  nevi,  including  the  pigmented  ones  and  the  very 
vascular  ones,  very  rarely  become  malignant,  but  occasionally  do. 
On  the  other  hand,  the  lesions  resulting  from  tar  irritation  and  f I'om 
the  x-rays  very  frequently  undergo  cancerous  degenerations.  In- 
flammatory lesions  only  exceptionally  become  malignant ;  perhaps 
more  cases  of  lupus  vulgaris  undergo  this  transformation  than  any 
other  inflammatory  conditions.  The  common  leg  ulcers  very  excep- 
tionally degenerate. 

And  yet  it  must  be  remembered  that  every  abnormality  of  the 
skin  is  a  potential  cancer,  and  that  cancer  practically  never  originates 
except  upon  the  site  of  some  pathological  condition,  be  it  congenital 
or   acquired. 

Prickle-Celled  Cancer. — In  cases  of  prickle-celled  cancer,  even 
upon  the  lip  or  penis,  the  prognosis  is  good  if  the  cases  are  seen 
early  and  if  a  complete  operation  is  then  performed.  Bloodgood^ 
states  that  40  percent  of  all  cases  of  prickle-celled  cancer,  no  mat- 
ter if  situated  upon  the  tongue  or  other  mucous  membranes,  and  no 
matter  how  extensive,  have  been  cured  permanently  at  the  Johns 
Hopkins  Hospital.  And  Bloodgood  does  not  consider  a  case  cured 
if  it  remains  alive  six  months  after  operation;  he  is  more  exacting. 
In  early  cases  of  cancer  of  the  lip  at  least   90  percent   should  be 


^Bloodgood:  Amer.   Jour.   Med.    Sc,   1014.   cxlvii,   76. 

169 


170  SKIN    CANCER. 

cured  by  a  complete  operntion.  and  al)out  70  percent  of  the  late 
cases.  In  cancer  of  the  other  i)ortions  of  the  skin  of  the  body  a 
very  high  percentage  should  be  cured  if  taken  in  time,  and,  in  con- 
sidering all  classes  of  cases,  the  iiorcentnge  of  cures  slionhl  Ix'  well 
over  50  ]>er('eut. 

Cuboidal-Celled  Cancer.  In  Hlondgood's  sei-ios  of  culxtidal-celled 
growths  the  percentage  of  cures  was  only  33  percent,  but  this  in- 
cluded many  tumors  of  all  stages  and  locations.  If  seen  early,  the 
]>ercentage  of  permanent  cures  should  be  much  higher  than  that  of 
the  squamous-celled  neoplasms. 

Baso-Celled  Cancer. — Of  the  baso-celled  growtlis  70  pci-  cent  have 
been  pennanontly  cured,  and  these  figures  include  even  the  inoper- 
able cases.  AVhen  the  growth  is  not  over  2  cm.  in  diameter.  100 
percent  should  be  cured  by  a  sufficiently  radical  treatment.  In  the 
more  advanced  cases,  or  where  there  is  invasion  of  some  of  the  nat- 
ural openings  of  the  face,  the  outlook  is  not  so  good.  Init  neverthe- 
less is  not  always  ho])eless  by  any  manner  of  means. 

Sarcoma. — In  regard  to  sarcoma,  Rloodgood  furnishes  us  with 
some  mo.st  interesting  .statistics.  In  six  cases  of  "poritlu-linl  angio- 
sarcoma" arising  from  a  congenital  nevus,  there  was  but  one  cure; 
in  eight  similar  cases,  but  arising  dc  novo,  there  was  not  one  cure. 
Twenty  cases  of  sarcoma  developed  in  scars;  of  these  eight  were 
cured,  five  lost  track  of,  and  the  reminder  not  cured.  "In  every  one 
of  these  cases  the  growth  in  the  scar  had  continued  one  or  more 
years,  so  that  in  every  case  there  was  sufficient  clinical  indication 
for  an  earlier  intervention.  Now.  if  the  probability  of  a  cure  be 
50  percent  in  late  intervention,  we  can  l)e  (|uite  sure  that  it  will  be 
much  greater  in  early  intervention."  In  nine  cases  of  sarcoma  of 
the  skin  there  was  a  history  of  a  preexist iiiu-  fi])i'onia.  and  only  five 
of  these  cases  have  remained  Avell. 

The  multiple  sarcomata  vary  in  maligiumcy.  In  the  small  round- 
celled  cases  the  outlook  is  hopeless.  l)ut  in  the  Kaposi  and  Spiegler- 
Fendt  types  the  outlook  is  better,  although  most  of  the  patients  hav- 
ing the  Kaposi  variety  eventually  die.  yet  the  patient  may  survive 
for  a  number  of  years. 

Nevocarcinomata. — Tlie  nevocareinomala  and  tlie  melanoniata  are 
usually  hoju'less  from  the  onset,  for  metastases  have  usually  taken 
place  by  the  time  the  patient  notices  the  finst  change  in  the  mole. 

Cancer  of  Cutaneous  Appendages. — The  prognosis  in  the  cancers 
arising  from  the  various  appendages  of  the  skin,  as  well  as  the  en- 
dothelial group,  is  faii-ly  good,  for  a  sufficiently  broad  local  incision 
will  nsuallv  cui'e  l)oth  of  these  conditions. 


PROONOSIS.  171 

Development. — The  stage  of  Hie  disc'isc  li;is,  of  coufsf,  ;i  most, 
important  bearing,  for  an  early  prickhj-f^jllcd  cancel-  is  mucli  easier 
to  treat  and  has  a  much  lietter  outlook  th;in  a,  \cry  advanced  basal- 
celled  neoplasm.  With  the  exception  of  tlic  nevocarcinoma  group, 
the  i)rognosis  of  all  early  tumors  is  good,  for  every  tumor  is  cur- 
able in  some  stage  of  its  existence.  Even  in  fairly  well-advanced 
growths  of  almost  any  variety  the  i)rognosis  is  not  absolutely  hope- 
less if  the  tumor  is  so  situat('<l  th;it  ii  complclc  of)f>r;i1ion  c;in  be  pci*- 
formed. 

Location.— 'JMic  location  of  llic  ncophisin  is  vcvy  iiii])ortaiit  in 
determining  the  outcome,  as  well  as  the  utility  of  the  organ  involved. 
In  c;incor  of  the  face  there  is  an  unfortunate  tendency  to  do  too 
limited  ;iii  ()i)erati()n  because  of  the  fear  of  deformity.  Upon  the 
eyelids  or  ears  a  complete  operation  is  not  only  difficult,  but  very 
deforming.  Upon  the  lip  the  prognosis  is  genei-ally  good,  for,  as 
alrcndy  stated,  the  figures  from  Maj'os  show  that  ovei-  80  percent  of 
the  early  cases  can  be  permanently  cured,  and  about  70  percent  of 
the  late  and  recurrent  cases  give  good  results  if  submitted  to  a  rad- 
ical operation. 

Tumors  situated  upon  the  limbs  or  body  can  usually  be  cured  even 
at  a  fairly  late  stage,  for  here  a  large  operation  can  be  done  Avith 
the  more  than  fair  chance  of  removing  all  of  the  cancerous  tissue, 
even  if  some  of  it  be  in  the  lymphatic  glands.  Upon  the  penis  the 
outlook  is  not  so  good,  for  cure  demands  the  complete  removal  of 
that  organ  and  of  the  neighboring  lymphatic  glands,  and  even  then 
only  about  half  of  the  early  cases  are  cured.  In  the  rare  tumors 
of  the  basal-celled  variety  the  outlook  is  much  better,  for  local  re- 
moval will  generally  cure. 

Operator. — The  skill  of  the  operator  is  essential.  In  the  first 
place,  the  surgeon  or  dermatologist  should  be  able  to  accurately 
diagnose  his  case  before  operation,  preferably  without  the  use  of  a 
biopsy,  for,  as  already  pointed  out,  a  biopsy  may  be  dangerous,  in- 
asmuch as  it  may  allow  cancer  cells  to  escape  into  the  cut  blood  ves- 
sels or  lymphatics.  In  some  cases  it  is  impossible  to  diagnose  a 
growth  until  the  time  of  operation,  and  then  a  surgeon  should  be 
sufficiently  skillful  as  a  gross  pathologist  to  immediately  tell  what 
the  character  of  the  tumor  is,  and  hence  how  extensive  an  opera- 
tion is  necessary.  ] 

Complete  operations  should  be  done  in  one  sitting,  for  second 
operations  are  always  dangerous  for  two  reasons — first,  because 
of  the  effect  upon  the  general  health  of  the  patient,  and  sec- 
ond, there  must  of  necessity  be  a  In-eak  in  the  chain  of  complete 


172  SKIN    CANCER. 

vomoval,  aiul  a  fc^Y  cells  may  Ite  lol't  at  tlic  (lividin<r  lino  l)ot\vccn 
the  tissue  removed  at  the  ditTerent  operations. 

In  addition  to  this,  the  surgeon  must  know  just  how  mudi  tissue 
to  remove  and  just  how  to  remove  it.  as  well  as  uiidcislandiiiL;  how 
lU'oion^'ed   an   ordeal   the   patient    can   stand. 

it  is  freipientlx  the  fault  of  the  pli.vsiciau  that  the  ^n-owth  is  not 
renn)ved  at  an  I'arly  date;  the  diajj:nosis  of  cauct'i-  must  always  he 
l>roven  or  disiu'o\en  as  soon  as  the  growth  a])i)ears.  and  the  ex- 
l)ectant  plan  of  treatment  usuall\-  leads  to  very  had  results.  For- 
tunately the  ])rofession  has  awakened  to  the  danj^^'r  of  the  so-ealled 
l>i-eeaneerous  eonditions.  and  the  laity,  as  a  result,  are  much  hetter 
infoiMiinl  than  they  I'oi'iiierly  were.  10vei\\-  surgeon  has  commented 
on  the  innnhei-  of  i)atients  suffering  from  still  heiiijiii  aftli<'tions  of 
the  skin  a])plyinji-  for  adviee  and  treatment.  This  oiu^  fact  is  the 
most  hoi)eful  siu,-n  that  we  have  today  as  to  1h(>  ])ossil)ilities  of  jier- 
manent  results  in  tlu>  tii^ld  of  eaueer  therapy. 

Cancer  Quack. — The  so-ealled  cancer  quack  is  one  of  the  nien- 
aees  that  today  faces  the  puhlic.  The  quack  is  in  the  field  sim- 
ply for  the  money  that  he  can  secure  from  unfortunate  patients, 
and  in  99  percent  of  the  cases  he  is  ahsolutely  without  conscience  as 
to  the  manner  in  which  he  secures  this.  He  is  ])erfectly  w^illing  to 
tell  a  patient  that  any  kind  of  a  lesion  is  cancer  and  needs  immedi- 
ate and  expensive  treatment ;  he  is  ahsolutely  ignorant  regarding 
pathology,  and  makes  no  attempt  to  keep  track  of  his  results,  ex- 
cept in  the  hope  of  securing  more  money.  It  is  surprising  to  see 
how  many  of  the  hospital  patients  have  had  treatment  from  this 
group  of  men.  and  then  eventually  submit  to  a  grave  operation  be- 
cause of  the  loss  of  time. 

In  conclusion,  the  results  in  the  treatment  of  skin  cancer  are  much 
better  than  they  formei-ly  wei-e,  and  will  become  much  better  as  ad- 
vice is  sought  earlier. 


CHAPTER  XVII. 
PROPHYLAXIS. 

Discovery  of  Cancer.  I'ntil  \\\c  line  cause  ol'  caucci-  is  discm'- 
crcd  it  will  he  impossible  lo  prcvcii!  i1  in  a  truly  scientifif  and  ef- 
fective way,  and  henec  it  is  xcvy  necessai-y  that  the  etiolojry  he  coin- 
})lctcly  worked  out.  Foi-tunately  there  are  a  nuinher  of  hihoi-atorics 
now  established  that  are  endeavoi-ing^  to  solve  this  difficult  problem, 
and  there  is  no  doubt  that  some  day  one  of  them  will  sueeecd.  Sueh 
a  research,  however,  reciuires  funds,  and  it  is  absolutely  necessary 
that  these  institutions  be  supported. 

The  establishment  of  the  various  societies,  both  for  educational 
purposes  and  for  various  types  of  cancer  research,  is  one  of  the 
hopeful  signs  of  the  times,  for  the  public  must  be  educated  to  the 
point  where  they  will  seek  advice  before  the  cancerous  stage  is 
reached. 

Precancerous  Dermatoses. — In  a  more  or  less  general  soi-t  of  way 
we  know  that  cancers  of  the  skin  are  almost  invariably  preceded  In' 
some  variety  of  precancerous  condition,  be  it  congenital,  inflamma- 
tory, or  neoplastic.  In  the  first  place,  it  is  evidently  necessary  to 
prevent  these  precancerous  dermatoses  whenever  possible,  or  at  least 
to  remove  them  if  they  be  present.  Chronic  trauma  of  the  skin  or 
mucous  membrane  should  be  prevented,  jagged  teeth  should  never 
be  allowed  to  remain,  care  should  l)e  taken  to  prevent  burns  of  the 
lip  resulting  from  the  use  of  the  pipe,  cigar,  or  cigarette.  This 
means  that  a  fairly  long  stub  should  always  be  left  if  a  holder  is 
not  used.  There  is  no  doubt  that  cigarette  smoking  can  cause  a 
precancerous  dermatitis,  although  this  fact  is  not  dwelt  on  in  the 
literature.  Nor  should  the  skin  or  any  part  of  the  body  be  chroni- 
cally irritated,  either  by  articles  of  clothing  or  by  any  instrument 
of  trade.  One  should  not  persistently  rub  his  body  against  a  de.sk 
or  table ;  those  doing  manual  labor  should  protect  themselves  against 
trauma  by  suitable  pads.  A  truss  for  hernia  may  cause  cancer  by 
its  incessant  friction  and  pressure.  A  suspender  buckle  may  do  the 
same  thing;  in  fact,  the  possibilities  are  manifold. 

Occupation. — As  already  pointed  out,  certain  industries  more  than 
predispose  to  cancer  of  the  skin.     Schamlierg^  and  others  have  .shown 


1  Schaaiberg::  Jour.   Cutan.   Dis.,   1910,   xxviii.   644. 

173 


174  SKIN    CANCER. 

how  prevalent  this  ooiulition  is  in  those  wlut  are  foreed  to  handle 
the  various  ]n-oduets  of  tar  and  ]H'troleuni.  (hiinney  sweeps  were 
formerly  liahle  to  cancer  ol"  the  scrotum.  ( 'tiiiii>lote  eleanliness  Avould 
doubtless  save  soine  iiion  from  industrial  cancer  of  this  nature.  The 
majority  of  industrial  cancers  are.  liowever.  undouhtcdly  due  to  ex- 
cessive actinic  rays,  citlicr  ol"  the  sun  oi'  ot'  ihc  x-ray.  the  latter  be- 
in«;  much  the  more  daufxerous.  Those  who  arc  cxjKfsed  to  such  dan- 
g:ers  sliould  take  suitable  iii'ccautions.  lead  bcinfj:  the  material  easiest 
to  liainlle  th;il  is  iiii i>er\  ioiis  1o  the  l\(Hitjren  rays,  and  some  sort  of 
a  mask  suflicieiit  to  i>i'otect  from  the  sun's  rays. 

Congenital  Deformities. — While  it  is  generally  iccoiinizcd  that 
cancer  may  follow  in  the  wake  of  various  eonsenital  deformities  of 
the  skin,  still  there  is  a  widespread  feelinp:  that  operative  interfer- 
ence of  any  kind  as  applied  to  such  a  congenital  defect  is  very  dan- 
gerous and  apt  to  cause  cancer.  This  is  a  grievous  error.  Blood- 
good-  states  that  he  has  removed  with  the  knife  175  clinically  be- 
nign pigmented  moles,  some  of  which  already  showed  signs  of  ir- 
ritation, and  that  there  has  not  been  the  development  of  a  single 
malignant  tumor  in  this  series;  and  this  in  spite  of  the  assertions 
made  by  many  surgeons  and  dermatologists  that  it  is  dangerous  to 
excise  a  mole,  and  that  it  should  always  be  removed  Avith  the  cautery. 
As  already  stated,  every  pigmented  mole  that  appears  late  in  life, 
as  well  as  every  pigmented  mole  that  begins  to  grow  or  that  shows 
any  sign  of  irritation,  should  be  i-emoved  at  once ;  in  fact,  every 
pigmented  mole  that  is  liable  to  chronic  irritation  should  be  elimi- 
nated. The  large  more  or  less  pigmented  nevi  occasionally  become 
malignant,  giving  rise  to  either  sarcomas  or  carcinomas.  The  small 
ones,  if  excised,  never  give  rise  to  malignant  trouble,  but  in  the  mind 
of  the  author  it  is  doubtful  if  the  large  ones  should  be  touched  ex- 
cept for  cosmetic  reasons.  There  is  no  way  of  removing  these  large 
growtlis  and  li;i\iim-  the  wound  heal  by  first  intention:  tliey  can  be 
removed  only  by  electrolysis,  cauterization,  or  some  similar  method, 
and  in  these  cases  malignant  change  is  ju.st  as  apt  to  develop  upon 
the  scar  as  in  the  old  growth. 

Vascular  nevi  rarely  become  malignant,  but  when  they  do  they 
give  rise  to  a  virulent  type  of  sarcoma.  Still,  it  is  doubtful,  for 
the  reasons  stated  in  the  preceding  paragraph,  if  it  is  wise  to  re- 
move them  in  order  to  prevent  such  malignant  change  taking  place. 

The  various  types  of  benign  Avarts,  commonly  but  erroneously 
called  papillomata,  only  exceptionally  undergo  malignant  degenera- 
tion, but  every  one  that  is  exposed  to  trauma  should  be  excised. 


'Bloodgood:  Amer.  Jour.  Med.   Sc,  1914,  cxlvii,  76. 


riuji'JiVLAXis.  175 

Benign  Tumors.  TIk^  vfirioiis  Itciii^n  liimors  hcconu;  uifilit.MiJint 
much  oi'twicr  tliiui  is  conimoiily  .suf)poK('(l.  JilofxJf^ood  states  that 
in  the  Johns  Hopkins  clinic  there  have  been  406  cases  of  beni^cn 
connective  tissiu;  tumors  oj)era,te<I  upon  ;iii<l  I'^T)  fjiscs  of  sarcoma, 
a  high  percentage  of  which  had  their  origin  in  Ihc  siif)p<;,scdly  be- 
nign growths.  With  llic  single  exception  of  lipoinata,  which  ncvo)- 
become  maligiiaut,  and  of  keloids,  which  |ir;ictically  always  i-emairi 
benign,  the  ])robabilities  are  that  fiom  ."»  to  10  pcj'ceiit  of  all  fjlhei- 
subcutaneous  tumors  become  malignant  if  they  remain  undi.sturbed. 
Bloodgood  has  seen  three  cancers  developing  fi-om  sim[)le  wens.  In 
nine  of  his  cases  of  sarcoma  there  was  the  distinct  history  of  a  pre- 
existing fibroid  tumor,  and  only  sixty-seven  instances  of  benign 
fibroid  tumors.  Hence  he  deduces  that  in  about  13  percent  of  the 
cases  a  fibroid  becomes  malignant.  Bloodgood 's  article  should  be 
read  in  the  original  by  every  physician. 

Wounds, — Inasmuch  as  malignant  neoplasms  practically  neven 
arise  in  wounds  that  have  healed  by  first  intention,  we  should  en- 
deavor to  cure  all  of  the  inflammatory  conditions  of  the  skin  with- 
out leaving  any  scars.  Lupus  vulgaris  should  never  be  allowed  to 
drag  on,  but  should  have  drastic  treatment  when  first  seen.  Old 
fistulas  and  ulcers  should  never  be  allowed  to  remain  unhealed,  for. 
while  they  do  not  frequently  become  the  site  of  cancers,  still  each 
is  in  reality  a  potential  cancer  and  should  be  so  treated. 

Arsenic. — Also,  we  should  be  extremely  careful  about  prescrib- 
ing arsenic  in  large  doses  over  long  periods  of  time,  for,  as  al- 
ready shown,  this  may  result  m  the  comparatively  well-known  ar- 
senical keratoses  that  can  become  malignant  just  as  other  keratoses 
so  often  do. 

Keratoses. — Keratoses  are  undoubtedly  the  precancerous  derma- 
toses par  excellence,  and,  once  they  have  become  established,  shoidd 
be  thoroughly  removed.  This  can  be  done  by  excision,  or  by  the 
curette  and  caustic.  The  ordinary  senile  Avart  must  never  be  re- 
garded as  harmless,  for  over  5  percent  of  them  certainly  develop  in- 
to basal-celled  cancers. 

Education. — In  addition  to  a  search  for  the  cause  of  cancer  and 
the  attempt  to  prevent  the  development  of  precancerous  conditions, 
and  the  removal  of  them,  once  they  have  arisen,  a  number  of  other 
things  are  necessary  if  we  are  to  make  headway  against  this  dis- 
ease. We  must  educate  the  public  to  seek  advice  early,  and  we  must 
educate  the  family  physician  to  give  good  and  wise  counsel  when 
this  advice  is  sought. 


170  SKIN    CANCER, 

Thanks  to  tlu'  moilical  urotVssion  aiul  a  few  imhlic-spirited  pub- 
licatidus.  tlu'  piildii-  is  l)i'roiuin«i:  im»i-o  aiul  iwow  awakciiod  to  the 
ilanjjer  of  eancei"  aiul  tlie  j^^ood  i-esults  that  can  he  ulitaiiicd  when 
the  eondition  is  recognized  at  a  sufficiently  early  pei-iod.  and  every 
surfjeon  is  notinir  tiiat  lie  is  seein*;  not  only  nu»re  and  iiutre  of  early 
cancer,  but  more  and  more  cases  of  tlir  piccanccrous  conditions.  To 
a<,'ain  ([Uote  Hh)od^:ood  :  "It  is  interesting;  to  note  that  the  number 
of  tliese  beniirn  lesions  api)lyin<r  for  treatment  is  on  the  increase. 
Tj)  until  lino  the  percentajfe  of  these  was  but  U.  in  the  ])ast  two 
yi'ars  the  benij^n  precancerous  lesions  have  increased  to  80  i)ercent, 
and  the  relative  number  of  fully  developed  cancers  is  apparently  on 
the  diM-rease.  .  ,  .  .My  table  shows  that  between  the  years  1890 
and  l!n."5.  sixteen  i)atients  have  soujiht  advice  with  lesions  of  less 
than  a  month's  dui'ation.  (  Practicall\-  all  of  these  were  recent 
cases,  and  in  ix'oplc  who  have  been  I'cached  directly  l)y  the  educa- 
tion of  the  students  of  the  third  and  foui'th  year.)  Fifty  patients 
souirht  advice  within  two  months  after  the  onset  of  the  first  lesion; 
77  l)etween  three  and  six  months:  10!)  between  six  and  twelve  months; 
344  fi'om  one  to  ten  yeai's  or  iiioi'e.'"  In  the  \ast  majority  of  in- 
stances, however,  malignant  change  had  been  present  ui)ward  of  six 
months  before  oi)eration  was  perfoi-med.  In  speakinj?  of  eifjht  cases 
of  perithelia!  aiiiiiosarcoma  of  the  skin.  Blood^ood  says:  "In  five 
of  these  cases  the  tumor  had  been  present  one  or  more  years;  in  only 
thi-ee  cases  less  than  a  >cai'.  In  every  instance,  therefore,  there  had 
been  the  opjiortunity  for  an  earlier  complete  local  operation.  Not 
(»ne  of  these  ei^ht  cases  was  cured.  If  we  are  to  jxct  better  re- 
sults in  dealinii'  with  the  malijrnant  luinoi's  of  the  skin,  we  must 
.see  and  tivat  our  ])atients  at  an  earlier  date.  The  ])ublic  must  be 
tauo:ht  to  realize  that  nothing  can  be  gained  by  delay.  They  should 
further  be  taught  the  danger  of  consulting  men  who  are  ignorant 
and  mercenai'y.  and  absolutely  Avithout  conscience.  Every  physician 
should  have  at  hand  a  few  copies  of  the  American  ]\Iedical  Associa- 
tion's expo.se  of  tho.se  engaged  in  this  nefari(ms  trade. 

There  are.  of  course,  a  number  of  ways  in  whicli  the  public  can 
be  I'cached  in  such  nuitters.  but  in  my  judgnu'Ut  none  is  so  eft'ective 
as  the  ]H'i-sonal  ])lea  of  the  physician  to  a  ])atient  or  household  that 
Inis  confidence  in  liim.  Public  lectures,  and  ai'licles  conlributed  to 
the  daily  papers  ov  to  the  juiblic  nuigazines  have  but  a  transient  ef- 
fect, and  are  usually  speedily  forgotten.  And  just  foi-  this  reason 
it  is  necessary  that  every  qualifiecl  physician  and  every  end)ryonic 
])hysician  shall  have  imiu'cssed  on  him  the  danger  of  ])i-ccancerous 
affections,  and  should  be  taught  not  only  in  his  course  in  pathology, 


PKOI'lIYLAXIS.  177 

but  ;iJ.S()  ill  HUff^cry,  iiicdicinc,  ;iihI  dcniuitoloj^y,  the  fact,  l!i;i1  ;i  can- 
cer iKjai'Iy  alwuyH  ariscH  upon  tlu;  site;  oi"  an  a})iionii;ili1y,  ]>(■  it  con- 
genital or  ac(|iru'C(l.  And  in  inany  medical  hcIkhiIs  Ihis  is  not  suffi- 
ciently well  done.  It  is  unjust  to  hlaiiK;  the  buHy  practitioner  for 
neglecting  to  keep  up  with  these  advances  when  he  did  not  receive 
the  proper  instruction,  but  fortunately  the  ethicji!  iiicdif;d  Journals 
of  today  are  teaching  this  very  point,  and  emphasizing.'^  the  neces- 
sity of  recognizing  cancer  early.  If  the  physician  is  in  doubt,  there 
is  always  an  expert  within  call,  a  man  who  has  the  necessary  ability 
and  appai'atus  to  make  a  diagnosis. 


nrAPTKK   XVTTT. 
TREATMENT. 

Tn  (Icnliiiir  witli  llu'  troatinont  of  skin  cancers,  the  following  out- 
line \vill  1)0  followed : 

Surfjical. 
Knife. 

Actual  or  electric  cautery. 
Curette,  with  or  wiilioiit  the  use  of  a  caustic. 

Electrical. 

Electrolysis. 
Fulguration. 

Actinic. 
X-rays. 
Radium. 

Caustic. 

Nitric  acid. 

Sulphuric  acid. 

Acid  nitrate  of  mercury. 

Chromic  acid. 

Pyrogallic  acid. 

Caustic  potash. 

Arsenic. 

Silver  nitrate. 

Zinc  chloride. 

Congelation. 
Liquid  air. 
Carbon  dioxide  snow. 

Medication. 
Arsenic. 
Methylene  blue. 
Colloidal  copper  salts. 
Cancer  vaccine. 
Immune  sera. 
Supportative  treatment. 
Analgesics. 

178 


TREATMKiNT.  179 

Treatment  of  (•()ni|>lic;iii()iis. 
Tnreclioii. 
Ilc.iiiorrlin^c. 
Invasion  of  special  organs. 

Repair  of  deformities. 
Plastic  operations. 
Artificial  organs. 

Treatment  of  inopci-aljlc  cases. 

SURGICAL. 

Knife. — At  times  it  is  diflicult  to  decide  uliicli  is  the  best  form 
of  treatment  for  a  special  case.  The  patient  usually  dreads  the 
knife,  and  likewise  dreads  an  extensive  operation  for  a  small  growth, 
and  the  physician  must  first  gain  the  confidence  of  such  a  patient, 
and  then  point  out  the  dangers  incurred  by  doing  an  incomplete 
operation.  But,  in  addition  to  the  personality  of  the  patient,  the 
personality  of  the  neoplasm  must  also  be  considered,  and  this  the 
writer  has  endeavored  to  do  in  the  chapters  devoted  to  the  special 
varieties  of  tumors.  The  author  feels  that  excision  with  the  knife 
is  usually  the  preferable  way  in  which  to  treat  a  tumor,  for  in  this 
way  a  clean  operation  can  be  done  with  very  little  scarring,  and  it 
is  possible  to  obtain  a  section  of  the  tumor  for  microscopic  study. 
This  last  should  always  be  done,  for  in  no  other  way  have  we  a 
check  as  to  w^hat  we  are  doing.  The  treatment  of  cancer  without 
microscopical  study  is  about  as  satisfactory  as  trying  to  read  with- 
out eyes.  This  is  because  epithelial  tumors  vary  markedly  in  their 
malignancy  according  to  the  type  of  cell  from  which  they  spring, 
and  it  is  not  always  possible  to  make  a  diagnosis  from  a  naked  eye 
appearance  alone,  at  least  not  until  it  has  been  many  times  confirmed 
by  the  histological  study  of  similar  conditions.  Next  to  the  use  of 
the  x-ray,  the  knife  is  the  least  painful  of  all  modes  of  attack.  And 
lastly,  the  results  are  the  best,  so  far  as  one  can  judge  by  the  study 
of  statistics.  So  far  as  the  writer  knows,  no  dermatologist  has  kept 
an  accurate  list  of  statistics  of  the  cases  of  cancer  that  he  has  treated 
by  the  curette  or  the  caustic,  and  but  few  have  checked  up  their  x- 
ray  results.  So  at  the  present  time  we  can  say  that,  so  far  as 
statistics  go.  the  results  with  the  knife  are  infinitely  superior  to  the 
results  obtained  in  any  other  way.  Furthermore,  in  all  surgical 
clinics  it  is  noted  that  nearly  one-half  of  all  patients  Avho  apply  for 
treatment  because  of  skin  cancer  give  the  history  of  having  been 
treated  by  a  caustic  paste,  or  by  the  curette,  and  often  by  the  x-ray 


180  SKIN    CANCER. 

or  riuliuni.  At  the  s;mu>  tiiiio.  it  is  difticult  to  use  \\\v  kuifo  upon 
tumors  that  are  situated  uj)ou  the  nose,  eyelids  or  oars,  and  here 
some  other  form  of  treatment  must  usually  l)e  devised.  In  the  eases 
of  the  priekle-eellt'd  cancers  llu-  knife  is  the  only  proper  instrument, 
and  this  ])robahly  ai)i»lies  to  the  euhoidal-eelled  neophisms  as  well. 
Sarcomata,  endotheliomata.  and  the  tiunors  arisinjj:  from  the  f?lands 
of  the  skin  siiould  he  treated  by  no  other  method. 

Anesthesia. — llavini;-  once  tlecided  thai  tlie  lesion  is  to  be  ex- 
cised, thi'  form  of  anesthesia  must  next  \)v  det(M-mined.  In  the 
snuiller  tumors  it  is  usuall\'  possihU'  to  oixTate  umlcr  local  anesthesia, 
and  for  this  i)urpose  there  is  no  better  substance  than  the  well- 
known  Sehleich's  solution,  made  without  the  addition  of  morphine. 
Sehleich's  solution  is  essentially  a  one-tenth  of  one  ])ei-cent  solution 
of  eoeaine  in  noi-mal  salt  solution.  There  is  not  the  slightest  neces- 
sity for  using  a  stronger  solution  of  cocaine,  ])roviding  that  the  sur- 
geon properly  infiltrates  the  tissues.  In  fact,  the  use  of  more  tlian 
one-third  of  a  grain  of  cocaine  at  one  sitting  may  be  dangerous,^ 
the  patient  showing  either  excitement  or  depression.  It  is  very  con- 
venient to  add  a  few  drops  of  a  1  to  1,000  adicnalin  solution  to  the 
cocaine  mixture,  for  this  will  markedly  lessen  the  amount  of  the 
bleeding.  A  fine  needle  should  always  be  used,  so  that  the  solution 
will  not  escape  through  the  needle  track.  The  needle  is  inserted  at 
a  slight  distance  from  the  growth,  usually  about  half  an  inch,  and 
superficially  just  beneath  the  skin,  so  that  the  infiltration  can  be 
noted;  if  the  injection  be  made  deep  into  the  corium,  satisfactory  in- 
filtration will  not  ensue.  It  should  always  be  remcml)ered  that  it 
is  very  difficult  to  infiltrate  scar  tissue,  and  at  times  impossible,  so 
eases  showing  much  scarring  are  not  suitable  for  local  anesthesia. 
The  injection  of  the  anesthetic  mixture  must  be  kept  \\]\  through 
several  punctures,  until  not  only  the  tissue  in  and  beneath  the  tumor 
is  thoroughly  infiltrated,  but  also  an  area  at  least  one-half  an  inch 
beyond  its  margins.  Anesthesia  will  be  coiui)lete  at  the  end  of  two 
minutes,  if  not  earlier.  Before  using  a  local  anesthetic,  it  is  well 
to  make  one  or  two  little  scratches  of  the  skin  to  indicate  the  in- 
tended line  of  incision,  for  when  the  growth  and  surrounding  tis- 
sues arc  filled  with  fluid  the  original  boundaries  are  often  lost. 

In  extensive  cases  it  is  usually  necessary  to  employ  general  anes- 
thesia, and  in  growths  around  the  mouth  or  nose  there  is  great  need 
for  an  expert  anesthetist.  Ether  is  usually  oiiiplnyod  for  long  opera- 
tions, while  nitrous  oxide  and  oxygen   may  suffice   for  a  short  one. 

Disinfection. — In  tlie  majority  of  cases  it  is  best  to  disinfect  the 


»Cushny:  Ptiarmocology  ami  Therapeutics,  New  York,  1011,  313. 


TKKATMKNT.  181 

Hkin  will)  iodine  ;il)<)iit  leu  iniiiiilcs  Ix-foi-cr  bcj^iiiniii^'  flic  oiu;i-af ion. 
)'Cliiciu))(!i'iii^'  tliJil  1li('  iddiiu'  imisl  ;ilw;iys  Ix;  Jipplicil  \(t  ;i  1  horfiUf/liIy 
dry  surfacM'  in  order  lo  he  cfdciciit. 

Operation.  It  is  iisii;d  lo  l;d<c  (tii1  an  dlipt  ir;d-.slia|)i'd  \i\c<-r  of 
tissiK^,  tlie  line  oL'  incision  cxlcndinn'  never  less  than  oiK^-foiDlli  and 
j)i'efoi'a])ly  oiuvliall'  inch  heyond  the  niarj^ins  of  the  fjrowth  if  it  be 
small,  and  several  inches  beyond  if  it  be  larjjc  or  ra[)id]y  sj)read- 
ing.  The  direction  oi'  the  lonji^  axis  of  the  incision  must  be  carefully 
determined,  so  as  to  put  as  little  tension  as  |iossible  uiion  the  heal- 
ing scar,  and  also  so  as  to  make  the  line  of  the  healed  seal'  coincide 
as  nearly  as  i)ossible  with  the  normal  lines  of  the  skin.  Upon  the 
face  the  axis  of  the  oval  incision  should  also  run  in  th(i  .same  direc- 
tion as  the  lines  of  the  face  in  that  particular  spot  or  region. 

It  is  unnecessary  to  say  that  only  a  very  sharp  knife  should  be 
employed,  and  that  the  knife  should  never  touch  the  cancerous  tis- 
sue proper,  for  fear  of  implanting  some  of  the  cancer  cells  upon  the 
edges  of  the  wound.  If  any  of  the  instruments  touch  the  diseased 
tissue,  they  must  be  innnediately  discarded  and  fresh  ones  employed. 
The  incision  should  be  made  with  as  few  strokes  as  possible,  usually 
in  small  growths  one  to  each  side  will  suffice,  although  it  may  be 
necessary  to  make  one  or  two  more  in  the  depths  of  the  wound  in 
order  to  entirely  free  the  excised  mass  of  tissue,  which  should  at  once 
be  removed  and  laid  aside.  After  the  bleeding  has  been  checked, 
the  surgeon  should  examine  the  growth  with  his  naked  eye,  but 
should  not  handle  it.  An  assistant  should  section  it  and  hold  it 
for  the  operator  in  order  that  he  may  run  no  risk  of  contaminating 
his  hands.  The  tissue  should  then  be  preserved  for  microscopical 
examination. 

Closing"  the  Wound. — The  question  of  the  closing  of  the  wound 
is  a  serious  one.  The  writer  has  noticed  that  when  a  basal-celled 
cancer  recurred,  this  recurrence  almost  invariably  took  place  at  the 
edge  of  the  sear  and  not  in  the  depths  of  the  w'ound.  This  means 
one  of  two  things — either  that  the  incision  was  not  wide  enough 
or  that  implantation  took  place  on  the  edge.  In  practically  all  of 
his  more  recent  operations  he  has  cauterized  the  edges  of  the  cut 
with  either  pure  carbolic  acid  or  with  the  acid  nitrate  of  mercury, 
and  since  that  time  has  had  very  much  better  results,  although  the 
appearance  of  the  scar  has  not  been  nearly  so  good.  If  it  be  deter- 
mined to  close  the  Avound  by  first  intention,  silk  sutures  are  usually 
used,  and  a  sufficient  number  employed  to  accurately  approximate 
the  edges  throughout  their  entire  length.  This  is  especially  neces- 
sary if  there  be  much  tension.      The  needle  should  be  sufficiently 


1S2  SKIX    CANCER. 

stroii«r.  for  at  times  the  skin  is  remarkably  thick  and  leathery,  and 
l)rone  to  break  needles  unless  they  are  carefully  liandled.  The 
stitches  should  usually  be  removed  on  the  second  da> .  although  in 
cases  of  tension  this  may  not  be  possible.  At  first  the  wound  may 
be  dressed  with  silver  foil,  over  which  a  piece  of  sterile  gauze  is 
placed,  and  sealed  with  either  collodion  or  adhesive.  Or  the  wound 
may  be  painted  with  ioiline.  smeai-eil  with  a  little  sterile  ointment 
to  prevent  the  adhesion  of  the  gau/e  that  is  ])laced  next  to  it.  Af- 
ter the  stitches  have  been  removed,  a  little  more  iodine  may  be  add- 
ed, and  the  wound  dressed  with  cotton  and  collodion.  In  the  case 
of  a  small  growth  the  wound  should  be  entirely  healed  by  the  end 
of  the  tenth  day,  although  it  is  well  to  leave  collodion  on  for  a  few- 
days  longer  in  order  to  remove  strain  and  jirevont  the  j^ossihility 
of  the  edges  separating. 

Actual  or  Electric  Cautery. —  l-'oi-  many  years  some  surgeons  have 
felt  that,  when  they  employed  the  actual  cautery  rather  than  the 
knife,  there  was  less  danger  of  cancer  recurrence  in  the  edges  of  the 
scar.  llaLsted.  as  well  as  many  others,  has  noted  this  in  cancer  of 
the  breast.  Were  it  not  that  the  electric  cautery  is  liable  to  get  out 
of  order  in  the  ordinary  operating  room,  it  would  be  the  ideal  one. 
but,  as  it  is.  the  actual  cautery  is  the  moi-e  i-eliable.  Excision  can 
be  managed  by  the  cautery  as  well  as  by  the  knife,  although  in  the 
removed  tissue  it  is  imiiossible  to  determine  the  limits  of  the  neo- 
plasm. As  a  conseciuenee,  some  surgeons  prefer  to  excise  Avith  the 
knife  and  then  immediately  employ  the  cautery.  It  is  generally 
considered  somewhat  dangerous  to  emi)loy  the  actual  cautery  in  the 
presence  of  ether  fumes.  The  cautery  has  the  one  great  advantage 
over  the  knife  of  thoroughly  searing  the  edges  of  the  wound,  so  that 
no  cancer  cells  can  escape  into  the  vessels  or  become  iini)lanted  along 
the  line  of  incision.  In  extensive  cases  of  cancer  upon  the  limbs 
or  body  the  cautery  is  excellent,  although  it  cannot,  for  example,  be 
used  near  the  eye.  The  cautery  should  always  be  used  when  it  is 
not  possible  to  give  a  wide  margin,  as  in  lesions  of  the  tongue. 

Curette,  With  or  Without  Use  of  a  Caustic. — The  use  of  the  cu- 
rette without  following  it  by  a  cau.stic  of  some  kind  is  mentioned 
only  to  be  condemned.  An  occasional  case  may  be  cured  by  the 
vigorous  use  of  this  instrument,  but  a  brief  recollection  of  the  path- 
ologA'  of  a  cancer  will  show  that  it  cannot  reacli  the  cells  that  are 
progressing  into  the  still  health}'  tissue. 

If  a  wound  is,  however,  thoroughly  curetted  and  then  efficiently 
cauterized,  the  results  are  often  excellent.     Sherwell-  has  elaborated 


'Sheiwell:  Jour.  Cutan.  Dis.,  1010,   xxviii,   487. 


TREATMENT,  1 83 

a  inctliod  in  which  ho  om])]oys  tho  acid  nitrate  of  rnoi-fury  a.s  tho 
cautei'i/iiig  agent,  aiic]  has  liad  (ixcclleiit  results.  Other  dermatolo- 
gists, including  th(!  aiilhor,'  h;ive  likewise  ()l)t;iine(l  gofjd  resiills  fi'oiii 
its  employment.  Hie  following  ;iecoiiiit  is  1;ikeii  from  the  wj-itor'.s 
own  artiele  on  the  siibjeet. 

The  aei<l  niti'.-ite  of  mercury,  or  the  liqiuir  hydrargyri  nitratis  of 
the  Pharmacopo'iji,  is  made  by  dissolving  40  grams  of  the  red  oxidf; 
of  mercury  in  45  grams  chemically  pure  niti'ic  acid  and  15  grams 
of  distilled  water. 

The  method  is  applicable  to  basal-celled  cancers,  endothelioma, 
moles,  warts,  and  certain  chronic  infections,  such  as  lupus  vulgaris. 
Growths  of  the  eyelid  can  be  treated  with  very  good  results.  It  is 
possible  to  benefit,  if  not  cure,  rodent  ulcei's  of  very  considerable 
size.  In  my  judgment  this  method  should  not  be  employed  in  spino- 
celled  cancers,  as  this  variety  of  growth  usually  metastasizes  rapidly. 

Either  local  or  general  anesthesia  may  be  employed.  In  small 
superficial  groAvths  thorough  infiltration  wath  a  Sehleieh's  solution 
will  amply  suffice.  If  the  growth  to  be  removed  be  about  the  face, 
it  is  better  to  give  a  preliminary  injection  of  morphine  and  atropine, 
so  as  to  lessen  the  secretions. 

The  apparatus  needed  is  simple.  Two  or  three  curettes  of  va- 
rious sizes  (at  least  one  of  w^hich  must  be  sharp),  a  scalpel  in  case 
hard  fibrous  tissue  is  encountered,  forceps,  clamps,  and  especially 
a  good  actual  cautery  with  which  to  stop  bleeding,  comprise  the  in- 
struments. Four  glass  vessels  should  be  provided,  in  one  of  which 
the  acid  nitrate  is  placed,  another  contains  powdered  bicarbonate  of 
soda,  the  third  a  solution  of  sodium  bicarbonate,  and  the  foui'th  a 
1  to  1.000  solution  of  adrenalin.  In  operations  around  the  face  the 
solution  of  the  soda  is  essential  for  the  protection  of  the  eyes,  or 
of  the  mouth  or  nose.  In  addition,  there  should  be  plenty  of  cot- 
ton swabs. 

The  operation  is  straight  forAvard.  Once  the  patient  is  anesthe- 
tized, all  diseased  tissue  is  rapidly  and  thoroughly  curetted  away, 
the  small  curette  being  necessary  to  reach  into  the  various  ramifica- 
tions of  the  growth.  The  sense  of  touch  will  tell  when  one  is  deal- 
ing with  sound  or  diseased  tissue.  All  diseased  tissue  must  be  re- 
moved ;  one  must  not  consider  Avhat  the  scar  Avill  look  like,  for  the 
permanent  removal  of  a  malignant  groAvth  is  far  more  important 
than  speculation  as  to  the  cosmetic  result.  Curettage  being  com- 
pleted, the  bleeding  is  stopped  by  pressure,  by  the  use  of  the  ad- 
renalin, or  by  the  actual  cautery,  or.  if  necessary  AA'ith  clamps.     Af- 


^Hazen:  Washington  INled.  Annals,  1912.  xi.  24G. 


184  SKIN    CANCliH. 

tei"  the  field  is  outiivly  dry,  the  acid  is  applied  with  a  cotton  swab; 
this  is  alltiwi'd  to  aet  for  from  fifteen  to  twenty  minutes,  several  ap- 
plications beiny;  matir.  Dr.  Sherwell  considers  that  the  acid  has  a 
specific  action  ni)on  caiicci-  cells,  but  it  seems  to  llie  author  tliat  it 
is  simply  a  powerful  iind  deeply  actiiii;-  ciiuslic,  whidi  iiia\-  readily 
be  controlled.  The  dry  soda  is  then  applied  with  a  iiauze  sponge 
until  it  has  formed  a  crust  over  the  entire  area  eauteii/ed.  In  cases 
of  conj?enital  moles  it  is  fir.st  necessary  to  blister  the  skin  with  car- 
l)(in  dioxide  snow  or  with  eanthai'ides,  and  then  api)l\"  the  acid,  neu- 
tral i/.iuir  as  has  been  described. 

The  after-treatment  consists  in  kee])iii^'  llie  lesion  diy;  tlii'  thick 
black  crust  that  I'oi'iiis  after  neut  i-ali/.at  ion  is  a  sufficient  i)rotection 
for  the  wound.  Dr.  Sherwell  considers  that  in  epitlielioiim.  and  moi-e 
especially  in  sarcoma,  it  is  wise  to  administer  Fowler's  solution,  al- 
ternatinir  with  Donovan's  solution,  for  several  months.  There  is 
always  considerable  edenui  and  inllanunation  following:  the  opera- 
tion, but  this  needs  no  treatment,  and  is  undoubtedly  a  jrood  thing, 
as  the  inflanunation  may  suffice  to  kill  cancer  cells  that  may  have 
escaped. 

The  results,  both  inunediate  and  permanent,  are  excellent.  The 
scar  is  soft  and  Avhite,  and  to  be  approached  only  by  the  x-ray  sear; 
in  the  author's  hands  the  scar  resulting  fi-oin  the  deep  application 
of  the  carbon  dioxide  has  been  more  noticeable.  Sherwell  reports 
that  he  has  had  about  10  percent  of  recurrences,  most  of  which  have 
been  cured  by  a  second  operation. 

Of  course,  other  caustics  may  be  used  after  the  growth  has  been 
curetted  away;  one  may  use  silver  nitrate,  taking  care  to  obtain 
the  pure  silver  nitrate,  aiul  not  the  ordinary  lunar  caustic  stick. 
Some  men  prefer  to  apply  a  caustic  paste  and  allow  it  to  act  for 
several  hours  or  days,  as  the  case  may  be.  but  the  author  prefers 
the  immediate  cauterization  as  being  less  painful  and   iimre  efficient. 

An  oi)eration  of  this  kind  is  especially  useful  in  the  basal-celled 
growths  that  oi-iginate  upon  the  nose,  or  in  the  naso-facial  groove, 
upon  the  eyelids  or  upon  the  ears.  A  modification  of  the  operation 
that  has  yielded  excellent  results  in  the  hands  of  the  author,  at 
least  in  early  cases,  is  the  excision  of  the  growth  and  the  thorough 
cauterization  with  the  acid  nitrate.  This  has  the  advantage  of  giv- 
ing a  specimen  that  is  suitable  for  mici'oscoi)ic  study,  and  the  scai' 
is  sur])risingly  good.  Kven  in  very  extensive  cases  it  is  sometimes 
possible  to  hold  the  disease  in  check  foi-  a  number  of  years  and  ren- 
der the  patient  much  more  comfortable,  and  occasionally  a  cure  may 
result   in  an  apparently  hopeless  case.     Sherwell   I'cpoi-ts  a  numbei- 


TREATMENT,  IHf) 

of   CUrCH   in    iriHtJUlccs    wIutc    llic    orldl     is    iii\;i(|((|.    ;ill  li()i|</li    llif    eye 
is,  of  coui'.se,  lost. 

ELECTRICAL. 

Electrolysis. — By  soitu'  1lic  clcclric  needle  is  nse-l  in  one  of  iu(; 
wjiys  cilluir  the  cntii'c;  lesion  is  removed  hy  it,  or  nuino'fjiis  puiif- 
t\ii('s  are  made  into  it,  so  that  the  body  of  Uu;  j^rowih  is  destroyed. 
While  this  method  Avill  undoubtedly  eure  a  iiuinbcf  of  eases  of  the 
early  basal-eelled  neoplasms,  it  has  never  ;ii)i)(!;iled  to  the  author, 
because  it  affords  no  chance  for  liislo]o^ie;d  ex;iniin;il  ion  of  the 
fjjrowth,  and  because  one  cannot  be  cei'tain  that  he  hjis  fjone  beyond 
the  margins  of  the  growth.  It  would  seem  to  be  af)f)lir';d)le  only  in 
extremely  old  and  decrepit  persons  who  cannot  stand  a  more  severe 
operation.  An  ordinary  sixteen-cell  silver  chloride  batteiy  can  be 
used,  connecting  the  negative  pole  to  the  needle.  If  the  oi)erator  is 
willing  to  take  time,  there  is  no  necessity  of  causing  any  pain  to  the 
patient,  for  just  as  good  results  can  be  obtained  from  the  prolonged 
action  of  a  mild  current  as  from  the  rapid  action  of  a  strong  one. 

Fulguration. — Of  late  years  the  so-called  fulgui'alion  has  come 
into  some  prominence,  thanks  largely  to  the  work  of  de  Keating- 
Hart.  Both  the  method  of  application  and  the  results  vary  to  some 
extent  with  the  skill  of  the  operator.  Bainbridge*  has  recently  writ- 
ten a  concise  review  of  the  subject,  and  the  following  is  derived 
largely  from  his  paper. 

The  method  known  as  alfofrequcnt  cijfolosis,  altofrequent  scintil- 
lation, ejfleuvation,  etc.,  was  first  employed  by  Riviere,  of  Paris,  and 
was  described  by  him  in  1900.  He  advocated  removing  the  tumor 
by  surgical  means  and  then  applying  high  frequency  sparks.  A 
monopolar  or  bipolar  current,  with  a  short  spark,  of  high  frequency, 
high  tension,  and  low  amperage,  is  employed.  Or  a  special  apparatus 
using  a  monopolar  current  with  a  long  spark  may  he  used. 

Oscillatory  desiccation  (Clark)  consists  in  the  production  and  sus- 
taining of  heat  to  cause  the  dehydration  of  the  tissues  treated. 
This  is  accomplished  by  a  specialized,  oscillatory  high  frequency  cur- 
rent, delivered  from  a  fine  metal  point  and  then  through  the  air  to 
the  tissue. 

Tliermopenetration  was  first  described  by  de  Arsonval  in  1896. 
It  depends  on  the  power  of  the  high  frequency  current  to  cause  a 
decided  rise  in  temperature  in  tissues  interposed  between  two  elec- 
trodes.    De  Keating-Hart  has  used  this  method  to  render  the  tissues 


•■  Bainbridge:  Internat.    Clinics.    23d    ser..    iii,    26S. 


186  SKIN'    CAXCKU. 

more  rjuliosensitivo.  ;iiitl  by  NaLrclscliinidt  and  Doyoii  for  tlie  do- 
struetioii  of  iiODplasins. 

DiatJicnnii  or  trttnsIlK  diiji  was  cxperiiiiciitfd  witli  in  lltOT  by  Xa- 
gclschniidt.  of  Berlin,  von  Hreiult.  Preeps.  and  Ze\neck.  of  \'ienna, 
and  <le  Kraft,  of  New  York.  The  ai)i)aratus  employed  elevates  the 
tcnipcraturi'  of  the  dci'p  tissui's  to  au\-  ri'quircd  extent,  the  tumor 
beinfr  destroyed  by  eoaj^ulation.  Tlie  greater  the  amperajjre  employed 
the  iireater  the  heatiiiir.     The  voltaire  employed  is  relatively  low. 

The  term  hiix/htr  volhiizdlit))!  is  applied  b\'  Do.ncii  to  the  method 
in  which  tiie  electrode  of  the  appai-atus  is  hehl  a\\a\-  fi'oni  tlie  i>art 
under  treatment,  and  the  si)arks  allowed  to  play   upon  the  area. 

Fidguration  (do  Keatintr-Hart)  is  foumled  upon  the  premise  that 
the  monopolar  lonu.-  sjtarl';  of  hijjh  frequenex"  and  hinh  tension  aets 
not  only  upon  the  neoplasm,  but  upon  the  soil  on  which  the  neojilasm 
has  developed.  Dc  Keatin«;-ITart  claims  that  the  use  of  the  high 
fre(iuency  short  spark  at  a  low  tension  aets  as  a  tissue  stimulant, 
but  that  a  spark  of  the  minimum  length  of  8  em.  applied  for  a  suf- 
ficiently long  space  of  time  transforms  a  healthy  area  into  a  torpid 
wouml.  which  heals  lai'gely  by  the  contraction  of  the  surrounding 
healthy  tissue.  It  is  considered  that  the  same  process  that  prevents 
the  reformation  of  healthy  epidermis  after  fulguration  also  retards 
or  sui)presses  the  groAvth  of  cancer  cells. 

As  this  method  is  the  most  important  of  the  electrical  ones  before 
the  medical  jirofession  today,  it  nuiy  be  well  to  describe  the  ap- 
jiaratus  used.  The  generating  ap])aratus  consists  of  a  large  coil  and 
a  rapid  interru])ter.  which  converts  the  street  current  of  low  volt- 
asre  and  high  amperage  into  an  interrui)ted  current  of  high  voltage 
an.l  low  amperage.  The  high  frequency  api)aiatus  consists  of  an 
( >udiu  resonator,  with  spai'k  gap  and  condensei's  of  gi'eat  capacity. 
The  sterilizing  and  cooling  a]ii>aratus  compi'ises  an  air  pump,  driven 
by  an  elective  motor,  which  forces  aii-  thi'ough  an  electric  sterilizer, 
and  the  air  is  tinally  delivered  at  the  elect i-ode  cool  and  stei-ile.  The 
electrode  consists  of  a  metal  mandril  within  a  rubl)er  tube. 

The  first  step  in  the  operation  is  i)ui'ely  surgical,  consisting  of 
the  removal  of  the  diseased  tissue  as  com])letely  as  jiossible,  then  the 
spark  is  used  for  a  long  time,  using  sparks  of  high  fi'eciuency  and 
high  tension,  and  applying  them  to  the  entire  wound.  The  electrode 
should  be  kej)t  in  steady  motion,  and  no  carbonization  of  tissue 
should  result.  '"Ten  minutes  of  fulguration  should  be  used  on  an 
area  of  ten  square  centimeters." 

Bainbridge  wisely  concludes  his  arti(lc  by  .stating  that,  although 
nt  the  present  time  the  results  seem  good,  still  it  is  too  early  to  draw 


TREATMENT.  ]87 

iiny  too  0|)timiHtic  f'oiK'liisioiis,  ;i,  sliilcnicni  willi  whifli  ;ill  f;iir  ininflf;(l 
men  must  uj^rcc. 

ACTINIC. 

X-rays. — In  tlic  (•niployinciil  of  1Im'  x-f;i\s  I'or  llic  t  rent  mciil  of 
CcllH'CI",  tlirCG  luetliods  Ikivc  been  ;i(|\()c;itc<l  ;  flfsl,  the  t  rcnl  iiiMit  \)y 
fractioiijil  (loses;  second,  tlie  einployineiit  oL"  thrc'C  oi-  i'oiii-  larj^e 
doses;  and  last,  the  applieutiou  ol"  oik;  or  two  iiiaxinium  doses. 

111.  this  eouutry  the  first  na.iiicd  indliod  has  hccn  the  usual  one.' 
A  moderately  hard  tube  is  selected,  and  i)Ut  at  a  tjislance  of  about 
four  inches  from  the  lesion.  Exposures  vary  in  time  from  ten  to 
twenty  minutes,  and  are  given  at  intervals  of  two  to  four  days,  and 
continued  until  the  lesion  has  disappeared,  this  sometimes  requir- 
ing several  months.  It  is  necessary  to  produce  a  slight  dermatitis, 
but  not  a  severe  burn.  In  many  instances  very  excellent  results  have 
been  obtained  by  it — results  as  good  as  those  obtained  in  the  later 
methods.  As  experienced  and  excellent  an  x-ray  operator  as  Puscy 
still  believes  in  it.  At  a  recent  symposium  before  the  American  Med- 
ical Association  in  the  Section  on  Pharmacology  and  Therapeutics, 
Pusey'^  said :  "I  sympathize  thoroughly  with  the  scientific  ideals 
which  attempt  to  determine  the  limits  of  physiologic  safety  of  Ront- 
gen  ray  exposures,  but  up  to  the.  present  time  I  have  been  con- 
strained to  hesitate  to  adopt  the  maximum  dose  method  in  my  oa\ti 
practice.  I  have  done  this  for  three  reasons.  First,  I  am  sure  that 
I  have  had  my  best  results  by  a  teehnic  that  consists  of  fractional 
doses — not  of  a  few  heavy  applications.  Certainly  in  my  own  ex- 
perience the  attempt  at  a  radical  quick  dose  has  not  proved  as  ther- 
apeutically efficient  as  several  cumulative  doses.  In  the  second  place, 
I  cannot  get  away  from  the  feeling  that  we  are  running  a  consider- 
able amount  of  danger  in  the  use  of  massive  doses.  We  can  make 
all  of  the  factors  the  same  except  one,  and  that  is  the  factor  of  the 
individual,  the  personal  equation  of  the  patient.  At  any  rate,  I  do 
not  feel  that  one  patient  will  react  just  as  the  next  one  will.  If  I 
can  draw  any  conclusion  from  my  experience,  it  is  that  there  is  a 
difference  of  susceptibility  in  patients.  In  the  third  place,  to  give 
a  massive  dose  requires  attention  to  a  group  of  important  factors, 
and  I  think  that  in  routine  work  the  danger  of  some  error  is  not  to 
be  overlooked.  As  a  matter  of  fact,  I  have  been  consulted  today 
about  a  burn  following  a  massive  dose  of  Rontiren  ravs  for  destrov- 


^Pusey:  Principles  and  Practice  of  Dermatology.  Phila..   1907. 
Pusey  and  Caldwell:  Tiie   Rontgen  Rays  in  Therapeutics  and  Diagnosis.   New 
York.  1904. 

5  Pusey:  Jour.   Amer.  Med.  Assn.,   1913,   Ixi,   59S. 


188  SKIN    CANCER. 

in^  rinj;  worm,  so  that  the  idea  ol'  danger  is  not  ]niroly  a  theory. 
As  for  my  techiiic  I  irive  repeated  iloses  of  Kiintjjfen  rays  until  I  pro- 
duce my  elfi'et." 

In  sneh  a  metho<l  as  this  tlu're  are  several  necessities.  The  oper- 
ator must  thorouy:hl>  understand  the  capabilities  of  ])oth  his  ma- 
chine and  tube;  at  tiist  lie  inust  jiroeeed  carefully  until  ho  tests 
these  instrunuMits  out  nimn  each  particulai-  jtatient,  and  then  he  can 
i;ive  numerous  sitting's.  The  woik  is  prolouficd  and  )iecessarily 
rather  expensive,  and  the  i)atients  often  tire  of  it.  <  >f  cdnrse.  it  is 
absolutely  essential  that  all  oi"  the  sui-iouiidiiiL:-  skin  he  covered  with 
lead  foil,  so  that  neillief  nii  acute  liui-ii  iioi'  alroiiliy  and  telan<;i- 
ectases  can  follow. 

It  was  soon  found  that  two  exposui'cs  of  twenty  minutes  each, 
usinjj:  the  same  tube  and  the  same  amount  of  curi'ent.  were  just  as 
effective  as  nine  oi*  ten  exjxjsures  of  five  minutes  each,  jtrovided  that 
the  former  were  not  too  lonjf  separated.  These  iigures  arc,  of  coui'sc. 
merely  jjiven  in  )'ound  numbers — as  illustrations  and  not  as  abso- 
lute facts.  As  a  result,  many  men  bcffan  treatment  alonj;  these 
lines."  and  in  ^'cnernl  the  I'csults  wvw  just  as  pjood  as  li>-  lh(>  older 
method.  There  has  been  a  mai'ked  shortcninfj:  in  the  dui'ation  of  the 
treatment,  and  not  as  much  liability  to  ati'ophy  and  telangiectasis, 
but  some  danfjer  of  an  acute  burn.  Tlie  use  of  th(^  penetrometer  to 
measure  the  quality  of  the  rays  and  of  the  Sabouraud-Xoire  pastille 
to  measure  the  (pjantity  of  the  emanations  has  markedly  lessened 
this  danger,  but  it  is  still  pi'esent.  es])eci;illy  witli  the  inexperienced 
operator. 

The  natural  sc(iuence  of  this  treatment  was  to  give  one,  or  per- 
haps two,  massive  doses — doses  measured  accurately  both  as  to  quan- 
tity and  quality.  In  America  ]MacKee,  of  New  York,  has  been  the 
chief  exponent  of  this  idea,  although,  as  he  points  out,  the  method 
is  in  common  use  abroad,  and  his  results  have  been  excellent  (Figs. 
69,  70).  The  following  account  is  derived  from  his  various  papers 
on  the  subject,  and  from  my  own  ]iorsonnl  expoi-ience.  which  is  iden- 
tical with  MacKce's. 

^lacKee  and  Kemer''  claim  that  an  accurate  measurement  of  the 
dose  is  as  imi)o)-tant  in  Kontgen  I'ay  therapy  as  in  any  field  of  medi- 
cine; that  the  massive  dos(\  carefully  measui-ed,  is  both  accuj'ate  and 
scientific;  that  the  patient  is  spared  the  necessity  of  many  visits  to 
the  phy.sician's  office;  and   last,  that   this  foi-m   of  ti'catment  is  bct- 


'  I.iang(>:  Jour.    Amer.    Med.    A.s.'jn.,    1913.    Ixi,    556. 
"  MacKee  and  Remer:  New  York  Mert.  Jour.,  March  20.  1913. 
Amer.  Jour.   RontBfnoIopy,  Drc,  1913. 


TKKATMKxNT.  189 

tcr  llH^f;ip(Mi1ic;illy.  In  c.xpljiiiiiii^  the  last  point,,  Ihcy  Hay:  "Sev- 
eral years  ajjjo  it  was  ciistoinary  to  ap})ly  the  x-i-;iy  1o  ffjilhr-jionia  in 
very  small  doses  three  times  a  week.  It  was  tioI  iinconimdn  lo  liear 
oi"  ;>()  to  150  01'  more  treatments  l)cln<f  >/\\ct\  1o  one  p;i1icn1.  Thosf 
wlio  a,re  familiar  with  ])ast  results  will  i-eeollcct  tli;it  ;i  ff  rtnin  per- 
centage oi  the  patients  were  permanently  furcd,  while  in  ;iii  nn- 
i'oiiiuiately  ];\.y<j;v  proportion  rccurrenees  wei-e  eomnion.  Il  will  also 
he  recalled  that  the  recurrences  wei-e  not  only  resistant  to  further 
x-ray  treatment,  l)Ut  that  in  many  instances  the  lesions  failed  to  re- 
spond at  all,  and  even  became  so  m;di^n;iiit  that  they  could  not  be 
controlled  at  all.  There  weiT  instances,  too,  where  the  y)riniary  epi- 
thelioma underwent  involution  to  a  cei'tain  point,  and,  after  remain- 
ing (|uiescent  for  a  time,  bej^aii  to  assume  malignant  tendencies  while 
under  the  influence  of  the  ray. 

"As  apparatus  and  tcchnic  imi)rovcd  so  that  the  number  of  ex- 
posures in  a  o'ivcn  case  Avas  reduced,  the  unfavorable  results  and  the 
recidives  were  eorrespondinfi;ly  diminished  numerically.  In  other 
words,  the  nearer  the  treatment  had  approached  the  massive  dose 
method,  the  better  have  been  the  results.  The  application  of  small 
amounts  of  the  x-ray  to  the  skin  for  a  long  period  of  time  will  pro- 
duce atrophy,  telangiectasia,  pigmentation  with  or  without  erythema, 
and,  finally,  epithelioma — i.  e.,  a  condition  similar  to  xeroderma  pig- 
mentosum. It  might  be  mentioned  here  that  these  features  are  far 
less  likely  to  occur  if  a  well-filtered  ray  is  employed.  They  will 
develop,  however,  even  with  the  filtered  ray,  if  the  applications  are 
repeated  often  enough  and  are  continued  over  a  sufficiently  long 
period  of  time.  Is  it  not  possible,  therefore,  that  so  much  ray  ap- 
plied to  an  epithelioma  might  add  to  its  malignancy? 

"It  has  been  proved  absolutely  that  prolonged  and  excessive  ex- 
posure to  the  x-ray  can  produce  a  cancer.  It  would  seem  advisable, 
therefore,  in  the  treatment  of  epithelioma  with  the  x-ray  to  give  as 
nearly  as  possible  the  exact  or  minimal  amount  necessary  to  cure 
the  individual  case.  This  dose  may  be  divided  into  several  strong 
treatments,  but  not  into  unlimited  and  oft-repeated  mild  exposures." 

MacKee  and  Eemer  admit  that  their  results  are  no  better  than 
those  of  Pusey,  who  sticks  to  the  fractional  method  of  dosage,  but 
they  do  claim  that  Pusey 's  results  are  far  above  the  average  be- 
cause he  is  expert,  and  that  their  own  results  are  much  improved 
by  the  introduction  of  the  newer  method.  Their  technic.  to  quote 
their  oAvn  Avords,  is  as  follows : 

"For  the  information  of  the  reader  who  has  had  no  personal  ex- 
perience with  radiotherapy,  it  may  be  stated  that  there  are  the  di- 


190 


SKIN  canci:r. 


root  ami  iiulirect  mothotls  of  (lunlitative  and  ciiiantitativo  measure- 
ments. The  iiulirect  metliod  consists  of  jutl^in<;  the  quality  of  the 
ray  by  certain  fixed  standards,  the  technie  being  closely  associated 
■with  the  personal  equation,  because  hai-dly  any  two  radiolo«rists  em- 
ploy exactly  the  same  type  of  apparatus.     Briefly,  the  technie  is  as 


Fig.  69. — Basal-cell  epithelioma.  Twelve  years  ago  thi.s  patient  had  numerous  ul- 
cerating gummata,  one  of  which  was  at  the  site  of  the  present  lesion.  Anti- 
syphilitic  treatment  healed  all  lesions  excepting  one  upon  the  neck,  which  never 
at  any  time  entirely  healed.  Ulcer  has  progressed  considerably  in  past  two 
years  and  has  developed  a  ver>'  hard  border.  Histopathology  is  that  of  a  deep- 
seated  basal-cell  epithelioma.     (MacKee's  collection.) 

follows:  A  milliampercmeter  is  employed  to  ascertain  the  amount 
of  current  passing  through  the  tube,  the  milliamperage  employed 
being  the  same  in   every  ti'catinoiit.      Tho   nnodo   of  the  x-ray  tube 


'n;i;AT.\ii:x'r. 


101 


is  always  placed  ;i1  ;i  ^ixcii  iniiiilx'i'  of  iiidics  from  Ihr;  skin.  Tho 
parallel  spark  ga])  (ov  oilier  iiislrmiK'iit;,  uhicli  rcj^istcrs  the  resist- 
ance in  the  circuit,  is  adjusted  at  a  certain  distance.  By  working 
with  these  eoiist;ints,  lia\iii<^  liad  a  ji^reat  deal  of  ox})ericnee,  beinf? 
thorouf^'hly  a,e(|n;iiii1ed   wiili   ;dl   p;irts  oP  th<!  vai-ious  aj)pnr;i1iis  ein- 


Fig.  70. — As  a  result  of  one  massive  dose  of  x-ray  application,  consisting  of  H  S, 
B  10,  the  lesion  healed.  Eight  weeks  later  a  second  application  of  the  same 
quantity  and  quality  was  administered  as  a  prophylactic.  A  piece  of  the  scar 
was  removed  for  histological  study  and  no  evidence  of  malignancy  could  be 
detected.      (MacKee's   collection.) 


ployed  at  the  moment,  and,  above  all,  possessing  a  knowledge  of  all 
possible  sources  of  error,  one  is  enabled  to  estimate  the  penetration 
(quality)    and.  the  amount  of  ray  administered.     The  aceuracv  of 


r.'-  SKIN   CANCKU. 

this  toohnic.  while  boiii^'  sufticieiit  for  rci)oatcd  small  doses,  does 
not  ]>()ssess  the  exaetiiiy:  retiuireinents  of  the  massive  dose  metliod. 
This  view  may  have  to  he  modified  in  the  fntnre.  hut.  with  the  ex- 
eitinf^  apparatus  and  tubes  a\aih-ihh'  at  present.  \\i'  <hi  not  eonsicU'r 
that  our  jiosition  is  too  ski'ptieal. 

"The  direet  metlii>d  of  measurement  consists  of  utili/.iu'j:  many  of 
tlie  factors  of  the  iuilircct  tcchnic  willi  llic  aildilimi  of  cniiilov  Imlt 
instruments  designed  for  the  ]>urposi'  ol"  dircctl\  t'stimatin<;  the  (pial- 
ity  and  ([uantity  of  the  ray.  Theri'  ha\e  been  many  t\j)es  of  ap- 
])ai'atus  and  many  sehenu's  ad\anced  with  this  object  in  \ie\\.  There 
are,  for  instance,  the  lIol/,i<neeht  chromoradiometer  and  i-adiometer. 
the  Sabouraud-Xoii'e  radiometi-r.  tlie  IJordier  chromoradiometei-,  the 
r>oi'dier-(  Jalimard  units,  the  (iuiUeininot  Ihioroinel  ric  (|uai>t  iometer. 
the  KienbocU  i)hoto.Li-rapiiic  (|uantiometer.  the  Sehwar/.  i)iH'eii)itation 
radiometer,  the  llampson  i-adiometer.  and  many  devices  and  schemes 
ori^-inate<l  by  Fi-eund.  Schmiilt.  Ilaeuisch.  and  others  \'nv  the  estima- 
tion of  the  (piantity  of  the  ray  adnunistered.  Without  ^'oinj;  into 
detail,  we  believe  that  the  llol/.kneclit  i-adiometer  (not  the  chromo- 
radiometer). empb)yed  with  a  modified  teclmic.  is  llie  best  proced- 
ure to  follow  foi'  the  ])urpose.  In  oui-  liands  tliis  technic  has  ])roved 
eminently  satisfactory,  and.  altlioujih  not  theoretically  accurate  or 
'fool  proof,'  the  possibility  of  error,  in  the  hands  of  the  experienced 
ojieratoi-.   is  reduced  to  the  minimum. 

"This  idea  of  estimatinjr  the  (piantit}'  of  the  ra\"  is  l)ased  on  the 
change  in  color  of  a  tablet  of  ])hitinocyanide  of  bai'ium  which  has 
been  exposed  to  the  x-ray.  A  standard  color  scale  is  utilized  for  eom- 
jiarison.  The  color  chanjies  are  estimated  in  Holzkneclit  (H)  units. 
The  unit  1  II  is  one-third  of  that  quantity  of  ray  which  can  induce 
a  mild  erythema  on  the  face  in  an  adult.  The  dose  varies  with  the 
a<;e  of  the  individual  and  the  ])art  of  tlie  body  exposed.  Skin  that 
has  \)vvn  exposed  to  irritating?  chemicals  will  i-espond  more  quickly 
than  normal  skin.  Fair  skin  is  sliiirlitix-  more  susceptible  than  dark 
skin.  Beyond  these  variations  it  is  a  \-ery  I'air  thin<i'  to  see  an  ex- 
amj)]e  of  hypersusceptibility. 

"Many  instruments  have  also  been  designed  foi-  tlie  puifxise  of 
judging  the  penetration  or  fjuality  of  the  ray.  ]\Iost  notal)ie  ai'c  the 
Benoi.st  radiochrometer.  the  Benoist-AValter.  the  "Wehnelt,  and  the 
Walter  .scales.  AVe  liave  found  the  Benoist  radincliromoineter  suf- 
ficiently satisfactory  foi-  this  pui-i)0se. " 

In  their  woi-k,  ^MacKec  and  Remer  have  found  it  better  to  u.sc  a 
"hai'd"  tube:  in  the  superficial  type  of  cancers  they  em])loy  a  B  8 
tulie,  and  in  the  d('ei)er  type  they  may  use  a  P>  10  1ul)e— that  is.  a 


TIIKATMKNT,  ]0.'> 

tubo  lliiil:  will  iiicjisiii'c  S  (»!•  10  nulls  l»\'  tlu'  I'.cnoisf  sf-alc  uIk'H  U'sIrT] 
for  ])en('trii1i()ii. 

The  t('<*hiii('  \'*>\-  iiiciisiii'iii;^'  '|ii;iiili1y  iiicfils  ;i  soiiicu  li;it  i'ullcr  <U> 
Ncript  ion,  r(»i-  il  is  iiol  <4ciicr;ill  \'  cm  iiloycd  in  this  country.  Tin; 
jlol/knccht  vjulioinclci-  consists  ol'  ;i  snilnhly  tinted  celluloid  l);ind. 
the  colors  of  which  ^-radc  from  zero  1o  S  II  units.  The  measurement 
])ie('(\s  consist  ol'  past.ils  of  plat  inocyanide  of  Itarium.  and  the  estima- 
tion is  made  by  i)lacin^'  a  half  pastil  under  the  c(»lored  hand.  An- 
other half  pastil  is  exposed  to  the  eiimnations  of  the  tube,  while  the 
patient  is  under  treatment,  c()vcre(|  with  eellidoid.  and  |ilaced  in 
ccmtaet  with  the  "index"  half  ])astil,  but  outside  of  the  colored  hand. 
The  whole  jiastil  is  now  moved  down  the  scale  until  the  two  halves 
match  exactly  in  color,  and  a  reading'  is  then  made,  somewhat  as  on 
a  hemojU'lobinometer. 

As  regards  dosage,  the  Ilolzknecht  units  are  now  jd'etty  generally 
known  and  used.  As  already  stated,  1  unit  ef|uals  a  dose  that  is  one- 
third  hirge  enough  to  produce  erythema  of  the  face  in  an  adult. 
The  H  units  are  accurate  only  when  a  ''medium"  tube  is  employed 
— a  B  6  tube,  for  instance.  It  is  necessary  to  remember  that  5  H  with 
a  hard  tube  may  produce  only  a  temporary  alopecia,  Avhile  the  same 
dose  with  a  soft  tube  may  cause  permanent  baldness,  and  hence  it 
can  be  seen  that  the  biological  effects  of  the  H  units  vary  according 
to  the  quality  of  the  ray.  As  a  general  rule,  from  5  to  7  H  units 
are  employed  at  the  first  sitting,  and,  if  necessary,  four  weeks  later 
another  dose  of  about  the  same  size  given. 

Regarding  the  "skin  distance"  and  the  "pastil  distance,"  the  au- 
thors say:  ''It  is  customary  to  place  the  pastil  exactly  half  way  be- 
tween the  anode  and  the  skin.  The  reason  for  this  is  that  the  pastil, 
being  closer  to  the  anode,  will  assume  a  deeper  color  when  in  this 
position  than  when  placed  upon  the  skin,  and,  therefore,  supposedly 
greater  latitude  is  obtained  in  estimating  the  change  in  tint.  Para- 
doxical as  it  may  seem,  the  deep  orange  shades  are  harder  to  match 
than  the  paler  colors.  Not  only  are  the  green,  yellow,  and  lighter 
orange  tints  easier  to  match,  but  they  do  not  fade  so  rapidly  when 
they  are  exposed  to  light  and  moisture.  Contrary  to  what  has  been 
published,  the  color  acquired'  by  an  exposed  pastil  will  fade  almost 
as  rapidly  under  the  influence  of  strong  artificial  light  as  by  the 
action  of  daylight,  and  the  deeper  orange  tints  will  attenuate  far 
more  rapidly  than  will  the  paler  colors.  These  are  some  of  the 
reasons  why  we  prefer  the  full  'skin  distance'  for  the  pastil.  There 
are,  also,  other  very  important  reasons.  The  numerals  on  the  scale 
of  units   of  the   Holzkneeht     instrument    are    not     equally    spaced. 


194  SKIN    CANCi:i{. 

One  has  more  latitiule  in  conipariii«?  the  liy:hter  than  in 
cstimatinj^  the  darker  tints.  The   pastil   must  be  placed 

at  least  one  inch  from  the  \v;dl  of  tlio  tube  to  avoid  the  deleterious 
effect  of  heat,  and  hence  the  tulii'  can  be  i)laced  nearer  the  patient 
and  the  exposure  shortened.  With  the  pastil  on  the  skin. 

re!?ardless  of  the  distance  of  the  aiKMk'.  the  H  units  must  be  multi- 
l)licd  by  foiw  to  conform  Avith  the  law  of  inverse  proportions  to  the 
.sciuare  of  the  distance — that  is  to  say,  if  1  II  unit  is  administered  in 
this  manner,  it  will  equal  4  II  units  by  the  "half  di.stance'  method." 

The  fresh  pastil  is  of  a  glazed  brilliant  green  color,  and  all  ])astils 
should  have  this  color,  approximately  at  least.  They  shouhl  ])e  kept 
in  a  well-ventilated  humidor  that  is  kept  in  a  cool  room.  A  used 
pastil  can  l)e  returned  to  almost  normal  color  1)\-  the  action  of  tlay- 
liglit  and  moisture.  Either  the  English.  Frencli,  or  (Jcrman  ]nistils 
may  be  u.scd.  for  all  seem  about  equally  reliable.  It  is  l)etter  to  use 
fresh  pastils  each  time. 

Now  a  word  as  to  the  choice  of  method.  Undoubtedly  it  is  better 
in  every  particular  to  use  as  little  x-ray  as  possible  in  the  treat- 
ment of  cutaneous  affections,  and  this  can  best  be  done  by  a  technie 
which  approaches  that  just  described.  At  any  rate,  we  should  make 
some  attempt  to  measure  our  doses — this  is  just  as  important  as  to 
standardize  the  drugs  that  we  administer  by  mouth.  To  the  author 
it  seems  certain  that  in  the  next  decade  practically  everyone  will  use 
instruments  of  precision  in  determining  not  only  the  quality.  1)ut 
the  quantity  of  the  rays  that  he  uses.  At  the  same  time  it  must  be 
remembered  that  very  bad  results  are  occasionally  obtained  when  one 
attempts  to  use  the  massive  dose.  Most  of  these  reports  have  come 
out  of  the  dry  states  in  the  west,  where  there  is  a  comparatively  low 
humidity,  and  it  seems  possible  that  the  lack  of  moisture  may  af- 
fect the  sensitiveness  of  the  pastils;  at  any  rate,  there  have  been  a 
number  of  very  bad  burns  reported.  Also,  it  is  more  than  possible 
that  all  skins  do  not  act  equally,  and  that  wliat  one  skin  will  tolerate 
will  prove  very  irritating  to  the  next. 

The  results  of  x-ray  therapy  in  cancer  of  tlie  skin  liave  usually 
been  good  in  the  liands  of  experienced  men.  Pusey"  reports  72. .5- 
percent  of  successful  I'csults  in  111  unselected  cases,  com])rising  lioth 
the  basal-  and  prickle-celled  variety  of  cancer.  Still  later  Pusey^* 
admitted  only  two  failures  in  thirty-five  selected  cases  of  cancer  of 
the  lower  lip,  mainly,  however,  of  the  rodent  ulcer  variety.  Mac- 
Kee's  results  have  been  almost  uniforndy  good,  and  there  can  be 

•Pusey:  Jour.   Amer.   Med.   A.ssn..   1907,  xlix,   1215. 
"Pusey:  Jour.  Cutan.   Di.s.,  1013,   xxxi,  7.3. 


TKKATMKNT.  ]  OO 

Tio  doubt  that  the  x-ray  can  aff'oinf)lish  cuvch  in  vory  many  caHOM 
of  cutaneous  cancer,  provided  lliat  no  metastasis  has  taken  plaf-e  to 
the  neighboring^'  glands.  Tlic  results  -.we  nol,  liowciver,  as  sure  as 
they  are  with  the  knife,  for  we  find  a  ccsrtain  .pcrcoitage  of  cases 
that  arc  al)solutc]y  intraetaljle  to  the  rays,  thf;  treatment  is  usually 
more  pi'olonged,  and,  if  a,  dcrnialilis  b<'  produced,  the  treatment  is 
usually  more  paiirful.  And,  (inally,  in  the  hands  of  an  exf^ert  sur- 
geon there  is  not  a,  great  difTcrcnce  in  the  scai'ring  pi-oduced  by  the 
removal  of  a  small  tuiiioi-.  The  x-ray  has,  however,  a  great  field  of 
usefulness.  It  is  the  ideal  treatment  for  l)asal-cel]ed  cancers  of  the 
eyelids,  of  the  naso-facial  folds,  and  of  the  ears.  In  addition,  it  is 
useful  in  the  very  old,  who  cannot  well  sul)Miii  1o  an  operation,  and 
in  certain  very  extensive  cases  of  cutaneous  cancer.  In  some  of 
these  cases  it  will  render  the  patient  comfortable  and  prolong  life, 
even  if  it  will  not  cure.  The  general  tendency  is  for  the  x-ray  ex- 
pert to  belittle  surgery  and  for  the  surgeon  to  make  light  of  the 
rays,  whereas  in  reality  each  field  of  therapy  has  a  great  field  of  use- 
fulness. 

Radium — At  the  time  of  writing,  radium"  is  receiving  more  than 
its  share  of  notoriety,  both  in  the  daily  press  and  before  the  va- 
rious medical  societies,  as  a  cure  for  cutaneous  cancer.  In  fact, 
radium  seems  to  be  going  through  tjie  same  stages  that  the  x-ray 
has — first,  it  has  created  wild  enthusiasm,  then  deep  disgust,  and 
finally  it  has  found  its  true  place.  The  general  trend  of  opinion 
is  that  radium  must  be  used  in  large  quantities  and  the  application 
must  be  for  a  considerable  period — that  is  to  say,  the  present  ten- 
dency is  to  use  it  in  ''massive  doses"  just  as  in  the  case  of  the 
Rontgen  rays. 

While  the  greater  portion  of  the  radium  in  the  world  is  produced 
in  America,  it  has  been  used  much  more  abroad  than  at  home;  in 
fact,  the  majority  of  American  dermatologists  have  been  profoundly 
skeptical  concerning  its  value,  and  this  is  hardly  to  be  wondered  at 
when  one  considers  the  undue  enthusiasm  with  which  it  has  been 
advocated  by  certain  men  on  both  sides  of  the  Atlantic  ocean. 

Eadium  is  usually  employed  in  the  form  of  the  bromide.  Its  gen- 
eral action  seems  to  be  comparable  to  that  of  the  x-rays,  but  rather 
more  powerful.     It  is  knoAvn  that  three  classes  of  rays  are  given 

"Lawrence:  Radium  Therapy,  Melbourne,   I'Jll. 
Wickham:  Arch.   f.   Dermat.   u.    Syphil.,   1012,    cxi,    161. 
Wickham  et  Degrais:  Radiumtherapie,   2d   ed.,  Paris,  1912. 
Newcomet:  Internat.   Clinics,  23d  ser.,  ii,   268. 

WilUams  and  Ellsworth:  Jour.  Amer.   Med.  Assn.,   1913,   Ix,   1694. 
Simpson:  Jour.   Amer.   Med.   Assn.,    1913,   Ixi,   SO. 


196  SKIN    CANCr.R. 

oft*  l)y  it,  and  those  rays  are  eallotl  the  alpha  (a),  beta  (fi),  and 
•raniiiia  (y).  The  ali)ha  rays  possess  but  little  power  of  penetra- 
tion, and  nw  somewhat  deviable  by  a  ina^fnet.  They  ean  be  absorbed 
by  an  air  c-ushion  of  three  inehes  thiekness.  by  ^dass,  or  thin  alumi- 
num. The  beta  rays  have  mueh  more  i)enetrative  i)o\ver,  but  are 
metre  easily  dcxiati'd  by  the  ma<rnft.  ami  are  said  1o  eoineidc  with 
the  eathode  rays  of  a  ("i-ookes"  tul)e.  Wiekham  thinks  that  they 
have  curative  properties  of  their  own.  The  ^rannna  rays  jtenetrati' 
deeply  and  do  not  respond  to  ma^netie  inlluence.  and  will  easily 
pa.ss  throutrh  -  mm.  of  lead.  Kadium  also  ^ives  olT  an  emanation 
that  obi-ys  tlie  laws  of  teases,  and  that  has  Iteeome  useful  in  the  liehi 
of  therapy. 

When  employed  upon  superficial  cancei-s,  all  of  the  rays  are  usual- 
ly employed,  and  no  attempt  is  nuide  to  filter  out  the  softest,  which 
are  presumably  more  irritating;  to  the  skin.  Kadium  is  usually  kept 
in  aluminum  containers,  or  at  least  containers  with  aluminum  win- 
dows, and  these  are  broujtjht  in  dii-ect  contact  with  the  diseased  tis- 
sue. As  a  ffcncral  rule,  an  attempt  is  made  to  secure  "cross-fire" 
action — that  is  to  say.  radium  is  applied  to  several  sides  of  the 
jjrowth  at  the  same  time,  so  that  the  rays  will  cross  each  other,  and 
this  is  deemed  much  more  effective  than  Avhen  applied  at  one  point 
•only.  From  10  milligrams  up  are  iu)w  apjtlied  at  each  ])oint  and 
left  for  from  four  to  eight  hours.  It  is,  of  course,  essential  to 
have  I'adium  that  is  very  active,  and  many  specimens  are  lacking  in 
this  i-espect.  which  fact  undoul)tedly  explains  the  skepticism  with 
which  this  remedy  is  viewed  ])y  many  dermatologists  and  surgeons. 

The  rays  of  radium  nuirkedly  resend)le  the  x-rays  in  that  they 
have  an  undnubledly  selective  action  for  certain  diseased  cells,  clnef 
of  which  are  the  cancer  cells.  The  authoi-  has  seen  instances  in 
which  an  unsus])ected  focus  in  apjiarcntly  healthy  tissue  was  de- 
stroyed by  the  action  of  i-adium.  leaving  a  tin\-  ulcer.  The  rays  seem 
to  kill  the  cancer  cells,  oi-  at  least  to  inhibit  their  growth,  and  not 
to  inllame  the  nonual  ti.ssue  when  carefully  used.  At  the  same  time, 
it  must  be  remembered  tliat  very  sei'ious  burns  can  i-esult  fi-om  the 
use  of  radium.  l)urns  that  ai'C  in  every  way  comjjai-able  to  x-ray 
burns,  and  hence  the  i-emedy  must  always  be  used  with  great  care. 

There  can  be  no  doubt  tliat  large  (luantities  of  radium,  when  used 
for  a  number  of  hours,  can  favoi-ably  influence  the  disappearance 
of  cancer.  There  are  probably  only  two  styles  of  cancer  of  the  skin 
in  which  it  is  justifiable  to  use  it  as  a  routine — the  very  early  growths 
of  the  basal-celled  variety  that  are  situated  wliei'C  operation  would 
1)C   difficult   and   mutilating,   and   in    inoperable    growths.      While  a 


'ri;i;A'i'.\ii:N'r.  1!)7 

iininl)cr  of  men  in  Anicric;!  ;ii'c  ;il  |ii(scn1  <l;iiinili{?  l)riHijin1  rr-KultK. 
iuid  vvliilo  \Vi<*l\li;ini  :\\\*\  l)(i.'r;iis  li;i\c  ;il  liiiics  {UT'ornpliKlif-d  won- 
ders, Hie  jitlitude  ol"  the  ;iiilliiir  is  (the  of  jircfit  HkcptieiHin,  ;in<l  for 
this  lliere  are    llie    I'ollow  in;^'   reasons: 

1.  \lc,  at  the  present  time,  has  under  his  ea  re  three;  patients  who 
have  ])ccn  treatiul  wilh  radium  an(|  |ir(ihounc('d  cured,  when  in  I'cal- 
ity  this  was  not  Irue,  in  Iwo  inslanecs  a1  least  the.  disease  beinf; 
made  much   worse. 

2.  The  "cured"  cases  have  not  been  Jollowed  for  a  sufTicii'ntly 
loiifi;  space  of  time;  it  takes  at  least  three  years,  in  cancer  of  the 
skin,  before  one  can  ref^ard  a  patient  as  defini1el\-  eurr^d. 

3.  Because  one  cannot  be  absolulely  eei'lain  as  1o  tlie  quality 
of  the  radium  on  the  market. 

As  already  pointed  out,  the  onl}'  way  to  use  I'adiuin  is  in  "massive 
doses,"  and,  inasmuch  as  the  metal  is  extremely  expensive — and  in- 
asmuch as  at  least  $15,000  to  $20,000  worth  is  necessaiy  to  even 
make  a  beginning,  it  is  extremely  improbable  that  this  treatment 
can  ever  become  very  general.  Personally,  the  author  is  very  much 
inclined  to  agree  wdth  Bloodgood  in  his  statement  that  radium  as 
now  used  is  holding  back  the  correct  therapy  of  cancer,  and  is  a 
menace  rather  than  an  aid. 

At  the  same  time,  it  must  be  admitted  that  radium  can  do  great 
good. 

In  conclusion,  it  must  be  stated  that  the  last  word  has  not  been 
said  regarding  i-adium  therapy.  The  author  is  inclined  to  believe 
that  it  is  no  better  than  a  massive  dose  of  x-ray,  except  in  some 
few  cases  wdiere  the  rays  have  failed,  and  even  here  radium  is  apt 
to  prove  useless.  Its  application  is  more  convenient  than  that  of 
the  rays,  but  it  is  more  dii^cult  to  gauge  the  dosage.  We  should 
keep  an  open  mind  on  the  subject  at  present. 

AVithin  the  past  year  or  two  mesotlwrium  has  been  used  by  some 
clinicians  as  a  substitute  for  radium,  as  it  is  much  less  expen.sive. 
It  seems,  how-ever,  not  to  be  as  effective,  although  opinions  as  to  the 
degree  of  difference  still  vary,  but  all  observers  are  agreed  that  in 
the  course  of  four  or  five  years  it  entirely  loses  its  radioactivity. 
The  same  statements  would  seem  to  apply  to  thorium-x  and  radio- 
thorium,  while  the  emanations  from  uranium  are  extremely  feeble. 

The  proprietary  remedy  ilwrcmcdin  has  been  carefully  studied  by 
Pusey,^-  who  reports  that  its  beneficial  results  were  entirely  due  to 
the  amount  of  sulphuric  acid  contained. 


'^Pusey:  Jour.  Airer.  Med.  Assn.,   1012,  Iviii,  715. 


198  .SKIN    CANCKR. 

Nitric  Acid. — Xitrie  acid  lias  hoon  very  little  used  as  a  caustic 
in  casts  111"  skill  cancer,  altliouufh  it  is  fjreatly  used  in  such  horny 
growths  as  warts.  This  lack  of  use  is  rather  surprisiiif?.  when  one 
considers  that  it  is  a  deei)-actin«!:  caustic,  and  that  it  can  be  speedily 
neutralized  by  an  alkali.  Po.ssibly  the  reason  is  that  the  physicians 
fear  the  pain  rcsultin<i:  from  its  apjilication.  At  ;iiiy  rate,  it  is  cer- 
tain that  the  scar  resulting  from  its  use  is  not  as  good  as  thai  nh- 
tniiictl  fj-din  the  action  of  many  othei'  cau.stics. 

Sulphuric  Acid. — Suli)hui'ic  acid''  has  in-aclically  the  same  ac- 
tion as  nitric  acid.  luit.  as  a  general  rule  docs  not  act  so  deeply; 
it  is  ])i'actically  iicwr  used. 

Acid.  Nitrate  of  Mercury. — The  acid  nitrate  of  mercury  has  been 
especially  extolled  by  :Siierwell  (see  page  182).  and  his  results  with 
it  have  been  excellent.  Of  course,  he  uses  it  by  first  curetting  away 
as  much  as  possible  of  the  new  growth,  and  tluu  allowing  the  acid 
to  act  for  at  least  fifteen  minutes,  finally  neutralizing  with  bicar- 
bonate of  soda,  as  has  largely  been  described.  Its  action  seems  to 
be   mncli   dco]ier  than  that   of   cither   acid    doscribod    n1)ovc. 

Chromic  Acid.- — ("hrumic  acid  is  but  little  used  in  dcnuatnlugy, 
except  in  an  attem])t  to  destroy  leuko]>lakia  upon  the  tongue.  The 
actual  cautery  can  well  replace  this  caustic. 

Pyrogallic  Acid. — Pyi-ogallol  is  considerably  used  by  some  men, 
largely  because  it  is  suj^jiosed  to  have  a  selective  action  and  to  spare 
healthy  tissue,  while  destroying  the  cancer  cells.  It  is  usually  em- 
ployed in  a  10  percent  strength,  but  the  author  agrees  with  Stel- 
wagon^*  that  this  is  entirely  too  Aveak,  and  that,  to  expect  any  re- 
sults, a  25  percent  strength  must  be  used.  The  following  i)rescrip- 
tion  would  be  about  correct : 

B   Pyrogalloli     ."ij 

Vasclini, 

EesinjB  cerati,  aa  partes  requalis  ad 3j 

This  mixture  is  s])read  ujjou  gauze  and  kept  closely  aj^plied  to 
the  cancer,  changing  the  dressing  twice  daily.  At  tlie  end  of  five 
to  eight  days  a  slough  Avill  form,  which  will  shortly  sc])arate,  or 
which  may  be  loosened  by  means  of  a  poultice.  The  ]»art  is  then 
cleaiLsed,  and  the  ti-eatment  continued  until  the  ])liysician  thinks 
that  sufficient  tissue  is  destroyed.  As  a  general  rule,  this  method 
has  one  commendation — the  lack  of  ])ain  caused. 


"Pu.sey:  Jour.  Amer.  Med.  Assn.,  101.3,  Ix,  434. 
"Stelwagon:  Diseases  of  the  SIfiii,  Phib..,  1914. 


TKKATMKNT.  1  Ijfj 


CAUSTICS. 


Caustic  Potash. — (!;uis1ic  poljisli''  is  ;i  iMtwcffnl  cjnisli'-.,  aii<l  unisl. 
!)(',  used  wiili  (';irc,  for  it  is  extremely  )';i|)i(l  in  its  ;if1ioii,  and  often 
thlH  action  is  iiiiicli  dccpei'  Hiaii  was  r»ri'jiii;illy  inlMxIfd.  The  eaUH- 
tic  stick  should  b(!  employed  r;itli(r  Ili;iii  1  Ik'  solution,  whi'-ji  may  be 
accidentally  (b-oppcti  upon  otli(!r  j^arts  than  intended.  Usually  only 
one  or  two  mimiles'  application  is  ]ieeessa ry,  and  the  further  action 
can  1)C  st()i)ped  by  acetic  acid  or  vinej^^ar.  The  use  of  this  caustic 
is  extremely  ])a-inrul  for  the  iiioment. 

Arsenious  Acid. — Arsenic,  or  i-athei-  arseinous  acid,  i.s  undoubt- 
edly the  most  popular  caustic  in  the  hands  of  the  dermatologists. 
It  is  frequently  employed  in  the  foi-m  of  Marsden's  paste,  which  is 
made  by  using  two  i)arts  of  arsenious  acid  and  one  part  of  mucilage 
of  acacia.  Arsenic  is  supposed  to  have  a  selective  action.  It  should 
never  be  applied  to  a  surface  more  than  one  inch  square  because  of 
the  possibility  of  absorption  and  consequent  poisoning.  Either  co- 
caine or  orthoform  is  usually  added  to  the  paste  to  lessen  the  pain 
of  application.  It  is  usually  allowed  to  act  for  from  twelve  to  thir- 
ty-six hours,  and  a  good  deal  of  inflanunation  results.  A  slough  re- 
sults at  the  seat  of  application,  which  separates  slowly.  Many  emi- 
nent dermatologists  extol  arsenic,  Gottheil,^*'  Marsden,  Robinson,^' 
Stelwagon,  and  others  thinking  very  highly  of  it. 

Silver  Nitrate. — Silver  nitrate  is  of  value  only  after  a  thorough 
curetting,  for  its  action  is  very  superficial,  owing  to  the  formation  of 
silver  albuminate  on  the  surface.  Care  should  he  taken  to  use  only 
the  pure  molded  silver  nitrate,  and  not  the  ordinary  lunar  caustic, 
which  is  greatly  inferior. 

This  caustic  should  not  be  used  after  cauterization :  a  more  deeply- 
acting  one  should  be  selected.  At  times  it  may  be  used  to  stop  oozing 
that  results  from  the  excision  of  a  small  neoplasm,  but  a  touch  \nth. 
the  actual  cautery  is  much  more  efficacious.  In  reality  this,  as  well 
as  practically  all  other  caustics,  could  be  well  dispensed  with  in  can- 
cer work. 

Zinc  Chloride. — Zinc  chloride  Avas  formerly  extensively  employed 
by  dermatologists,  and  still  constitutes  the  basis  of  many  quasi-can- 
cer  pastes.  This  salt  is  A^ery  painful  in  its  action,  and  destroys  healthy 
or  diseased  tissue  indifferently.  Its  action  is  peculiar  in  that  it 
seems  to  dry  up  the  tissue  rather  than  corrode  it.     It  is  most  com- 


"  Van  Harlingen:  Jour.   Cutan.   Dis.,   1906.  xxiv.   345. 
"Gottheil:  Treatment  of  Skin  Cancers,  Xew  York,  1S99. 
1' Robinson:  Internat.   Jour.   Surg.,   1S92,  179. 

Internat.   Jour.   Surg.,   1893,   164. 

New  York  Med.   Record,  Mar.   31,  1900. 


200  SKIX    CANCKK. 

inoiily  usfil  in  Xhv  foi-iii  known  as  rxiujzard's  i»astc,  the  formula  for 
which  is: 

li   Farinii'  tritici  (uiu-at    fli)ui), 

Pulvcris   aiiiyli,  na    oss 

Pulveris  arsoni  trioxiili    '^r.  iv 

l*nlvi'ris  liy(lrni<jyri  sulphidi  nihri. 

Pulvcris    ainiuoiiii    i-liluridi.    afi    av.  xx 

Pulveris  hydrarj^yri  chloridi   comisivi j;r.  ij 

Ziiici  chloridi  irvstaliisati    oiv 

A(|ua'    ftM\  ilia'    .^j 

The  first  six  injj:r(.'(ru'nls  aic  luixcd  sopai-atdy  and  the  zinc  chloride 
dissolved  in  the  water,  and  the  two  jiai-ts  then  i-uhhfd  n]^  torrether. 
It  takes  one  or  two  (hiys  for  any  aiuount  of  dcsl  iiidioii  to  take  jilaee, 
usually  one  or  two  apidicatioiis  ])eing  nccessai\".  This  jjrescription 
siiould  appeal  to  those  wlio  still  believe  in  ])olypliariiiacy.  the  "shot- 
iiun  artists." 

Formalin  is  extolU'd  hy  Kavoj.ili.'"  who  first  curettes  and  then  aj)- 
])lies  it  in  ecjual  dilution  Avith  civsol  and  i)erchloi'ide  of  iron.  He 
reports  excellent  results,  some  of  his  cases  having  been  followed  for 
many  years. 

In  general,  the  author  is  not  favorably  disi)osed  to  the  use  of 
caustic  pastes,  excei)t  after  either  curettage  or  excision  of  the  growth, 
or  in  the  case  of  extremely  old  or  feeble  iii(li\  iduals.  There  is  no 
doubt  that  many  of  the  small  l)asal-celled  neo])lasms  can  be  destroyed 
by  the  use  of  a  caustic  i)aste  alone,  but  the  mere  fact  that  very 
many  of  the  patients  with  cancer  of  the  skin  who  have  come  to  the 
Johns  Hopkins  Hospital  surgical  de])artment  foi'  opei'ation  have 
had  this  method  of  treatment  tried  upon  them  is  sut^cient  refuta- 
tion of  its  universal  efficiency.  In  these  eases  the  report  of  the  pa- 
tients invariabl.N'  was  that  the  treatment  was  exti'cmely  painful,  and 
that  it  left  a  large  ulcei"  that  was  extreiiiel\-  difficult  to  heal.  AVhen 
these  facts  are  explained  to  the  i)atien1,  it  is  usually  not  liiflicidf 
to  secure  his  consent  to  an  oi)eration.  In  ten  years'  jji-actice  the 
author  has  not  once  had  to  resort  to  a  caustic  i)aste  because  the 
patient  refused  operation.  As  already  pointed  out,  if  a  true  selec- 
tive action  exists,  which  in  many  instances  is  doubtful,  it  makes  the 
prognosis  infinitely  worse,  because  cancer  cells  arc  invariably  found 
invading  more  or  less  deep  down  in  the  healthy  tissue,  the  cancer 
cells  existing  in  .small  groups.  After  operation,  however,  the  use 
of  a  caustic  upon  the  edges  of  the  wound  undoubtedly  decreases  the 


"Ravogll:  Amer.   Jour.   Surg.,  May,   1013. 


'I'la-wX'I'MKNT.  201 

pcrcciitiiji'C!  of   rcciirrciiccs,   :iiiil    li;is   now    licfdinc  ;iltiios1    ;)    ronliiK'   in 
the  f)ru(tli('e  of  llu;  iiiitlior. 

CONGELATION. 

Liquid  Air  and  Carbon  Dioxide  Snow.  < 'oii-jchiiion  li;is  l»r<ii 
used  ill  two  foniis-  (ii'st  in  llic  Funn  n|'  li(|irnl  ;iir.''  whii-li  u;)s  al- 
ways difficult  to  obtain  and  more  difdcidt  1o  keep,  and  in  llic  iVji'/n 
of  carbon  dioxide  snow,  as  ad\(ic;i1c(|  by  Pnscy.-"  The  snow  is  l>cst 
obtained  l)y  loosely  screwing-  a  small  brass  rylindiT  1o  1lic  fnitlet 
valve  of  a  coniinereial  tube  of  the  ^'as,  wliidi  is  supplied  to  nil  di-utr- 
gists  for  the  purpose  of  ehai'jjjin^  theii-  soda  wa1  cr,  and  linn  tit.ditly 
tying  a  piece  of  chamois  over  tlie  end  of  the  tube.  In  ihis  way  a 
molded  i)eneil  of  the  snow  is  obtained  i-eady  foi*  use.  Jt  is  best 
handled  in  a  pair  of  heavy,  lined  automobile  gloves,  and  is  ajtpiied 
to  the  growth  for  from  one  to  three  minutes,  making  firm  pressure. 
The  action  is  essentially  caustic,  and  is  not  very  deep.  The  authoi- 
has  seen  it  used  in  only  four  instances  of  cancer,  and  in  all  of 
them  there  was  prompt  recuri-ence;  hence  he  does  not  advocate  this 
form  of  treatment.  Some  other  dermatologists,  however,  report  suc- 
cesses from  its  use. 

MEDICATION. 

Arsenic. — Arsenic  is  still  used  internally  by  a  few  men,  Sher- 
Avell,  in  particular,  advocating  it,  and  even  Pusey  seeming  to  think 
that  it  may  have  a  slight  inhibitive  action.  It  is  nsed  either  in  the 
form  of  FoAvler's  solution  or  as  Donovan's  solution,  the  maximum 
dose  usually  being  employed.  There  is  no  doubt  of  the  value  of  this 
form  of  treatment  in  sarcoid  and  in  the  border  line  cases  between 
sarcoid  and  sarcoma,  but  there  is  very  little  evidence  that  it  is  of 
any  value  in  true  cancer  of  the  skin,  other  than  acting  as  a  general 
tonic. 

Methylene  Blue. — The  internal  use  of  methylene  1)lue  has  l)een 
advocated  by  no  less  an  authority  than  Jacobi-^  in  internal  cancer, 
that  author  believing  that,  while  it  will  not  cure  the  disease,  it  will 
at  least  hold  it  in  cheek  for  some  time.  So  far  as  the  author  knows, 
the  internal  administration  of  this  drug  has  never  been  sho^^^l  to 
have  the  slightest  effect  upon  cutaneous  cancer. 


^"Dade:  Trans.  6th  Inter.  Dermat.  Con.,  1907,  ii,  672. 

Whitehouse:  Jour.  Amer.   Med.   Assn.,   1907,  xlix,  371. 
=>»  Pusey:  Jour.   Amer.    Med.   Assn.,    1907,    xlix,    1354. 
Jour.  Cutan.  Dis.,  1909,  xxvii,  32. 
Jour.   Cutan.  Dis.,  1910.  xxviii,  352. 
Low:  Carbonic-acid  Snow,   New  York,   1911. 
"Jacobi:  Jour.  Amer.  Med.  Assn.,  190G,  xlvii,  1545. 


202  SKIN    CANCKR. 

Colloidal  Copper  Salts. —  Witliiii  a  short  time  preparations  of  col- 
Ktidal  (M)i)j)er  have  been  injeeted  into  eancer  i)atient.s.  Loeb,  ]\Ie- 
Cliirg,  and  Sweek--  state  that  they  "'ai'e  now  a])le  to  eausc  the  grad- 
ual retrogression  of  human  oaneei*.  whieh  nntit  now  has  withstood 
variousinodes  of  tn-atment  ;  an<l.  furthermore,  that  the  treatment 
does  not  seem  to  be  limited  tu  tmc  kind  of  cancer,  but  applicable  in 
the  effective  treatment  of  various  kinds  of  cancer."  AVeil'--'  has  pul)- 
lished  a  i>a]ier  on  the  use  of  this  method  from  the  Cancer  Keseareh 
Service  of  the  Cornell  I'liiversity  ^ledical  School,  in  wliich  lie  de- 
tails his  experiments  with  and  his  elinieal  use  of  this  metliod,  and 
decides  that  this  form  of  treatment  is  ])robably  without  value.  Weil 
finds  that  tlie  injei-tions  are  not  \\cll  Ixinic.  that  1hc\-  ai-e  followed 
by  chills  and  rigoi's.  and  tliat  nausea  and  vomiting  are  very  common. 
In  addition  to  these  sym])toms.  there  is  usually  a  progressive  anemia. 
Locally,  there  may  result  cithei-  ])li]ebitis  or  ])eripldfbilis. 

Immune  Sera. — The  various  attempts  to  produce  either  an  active 
or  a  passixe  immunization  against  cancer  is  an  extremely  interesting 
one,  but  so  far  the  results  have  been  so  contradictory  that  it  would 
probal)ly  be  a  waste  of  time  to  attempt  a  description  of  even  a  few 
of  them.  The  literature  is  voluminous.  l)ut  speedily  becomes  obso- 
lete. 

A.  E.  Thayer,-'*  of  ^lo])ile.  has  recently  written  a  very  interesting 
paper  on  epitheliolysis  against  cancer.  lie  has  worked  on  the  as- 
sumi)tion,  now  well  grounded,  that  the  injection  of  cells  from  one 
animal  into  the  body  of  another  would  make  the  scrum  of  the  re- 
cipient animal  lytic  for  such  cells,  and  this  was  a  specific  reaction. 
In  addition,  the  carcinoma  cells  are  less  resistant  than  normal  cju- 
thelial  cells;  hence,  if  tlie  lytic  power  of  the  serum  could  be  raised, 
the  cancer  cells  would  be  the  first  destroyed.  In  one  case  of  in- 
operable cancer  of  the  uterus,  washed  autolyosates  of  cancer  were  in- 
jected with  apparently  beneficial  results.  ]\Iore  confirmation  is  nec- 
essary before  we  can  be  sure  of  our  ground. 

At  the  Freedmen's  Hospital  we  have  tried  to  produce  active  im- 
munization against  epithelial  cancer  in  a  few  eases.  This  was  done 
by  making  an  extract  of  a  cancer  of  a  similar  histological  origin, 
splitting  it  into  toxic  and  non-toxic  parts  as  suggested  by  Vaughan, 
and  using  injections  of  the  non-toxic  part  once  a  week.  The  results 
were  negative,  although  one  i)atient  did  state  tliat  tlie  injections  were 
distinctly  stimulating. 


"Loeb,  McClurg,  and  Sweek:  Inter.slate  Med.  Jour.,  Iftl2,  xix,   Uil,'>. 
='Weil:  Jour.  Amer.   Med.  Assn.,  1913,  Ixi.   1034. 
=»  Thayer:   .South.    Med.    Jmir..    101.'?.    vi.    i>r.-. 


TREATMENT.  203 

Mjuiy  att,einf)ts  have  been  made  In  IimIucc;  p;i,ssi\(:  inirtiudi/.jitjfni 
by  llio  iiijoclion  of  an  imniimo  scniin.  As  \\cvh-\cy  aiul  Bfclx/'^'' 
point  out,  tliis  tlicorcl ically  is  an  idcnl  1  i'c;il mcnl  \'i>\-  f-ancer,  for  it 
is  .soluble  in  the  ))lo()(l,  transinissii)lc  by  liic  l)loo<l  aiifl  lymph  to  all 
portions  of  the  ])0(ly,  and  should  possess  a  scleetive  affinity  for  the 
cancer  cells.  So  far  the  Yory  best  resuHs  oblnined  with  any  of  the 
methods  pi-oposed  are  sini])ly  mildly  oncouraf^inf^ — no  more. 

Supportative  Treatment. — In  ceitain  cases,  either  because  of  the 
advanced  age  of  the  patient,  because  of  the  extent  of  skin  involve- 
ment or  of  the  presence  of  a  severe  secondary  infection,  because  of 
some  other  organic  disease,  or  because  of  the  presence  of  cancerous 
metastases,  general  supportative  treatment  becomes  necessaiy.  In 
certain  of  these  cases  it  is  questionable  whether  it  w^ould  not  be  bet- 
ter to  do  a  palliative  operation,  if  only  for  the  moral  effect.  But  in 
these  instances  the  patient,  and  not  the  disease,  must  be  studied, 
and  each  victim  fui-nishes  a  radically  different  problem,  and  one  that 
must  be  solved  according  to  the  conscience  and  experience  of  the 
physician  in  charge,  he  usually  being  better  able  to  determine  in 
such  a  case  than  the  consulting  surgeon;  this  because  of  his  sup- 
posedly better  knowdedge  of  the  patient. 

Supportative  treatment,  in  general,  consists  of  fresh  air,  good  food, 
and  the  proper  amount  of  rest  or  amusement,  as  the  case  may  be. 
It  is  always  essential  to  have  an  air  of  good  cheer  around  such  a 
patient,  and  a  good  nurse  can  sometimes  accomplish  wonders. 

Analgesics. — So  far  as  medicines  go,  about  all  that  one  can  do 
is  to  employ  simple  tonics,  or  analgesics  if  necessary.  Concerning 
analgesics,  the  author  can  see  no  good  reason  for  A\ithholding  mor- 
phine from  a  patient  wdio  has  an  inoperable  cancer ;  to  him  it  seems 
needless  cruelty.  Of  course,  pain  can  often  be  relieved  by  dividing 
a  nerve  that  is  being  pressed  upon,  or  by  some  simple  operation, 
but  this  is  not  always  possible.  As  a  general  rule,  it  is  probably 
advisable  to  start  in  with  a  combination  of  codeine,  phenacetine.  and 
aspirin,  and  not  use  morphine  until  absolutely  necessary,  for  fear 
of  it  losing  some  of  its  effect  when  it  has  to  be  administered  over  a 
long  space  of  time.  It  must  likewise  be  remembered  that  either  the 
x-ray  or  radium  may  greatly  relieve  pain,  even  though  they  do  not 
cure  the  tumor.  Dressing  the  new  growth  with  charcoal,  or  -with 
some  mild  antiseptic  agent,  may  be  a  great  comfort.  An  ointment 
composed  of  one  dram  of  orthoform  to  an  ounce  of  any  fatty  base 
wdll  frequently  relieve  pain  from  exposed  nerve  endings. 


Berkeley  and  Beebe:  Med.   Record,   1912,   Ixxxi.   513. 


2(>4  SKIN     CANll.H. 

TREATMENT  OF  COMPLICATIONS. 

Infections.  W'lun  an  I'pit lu'lioina  has  \)v<.'\\  in  an  ulcei'ative  oon- 
(litinn  liii-  any  liiiiilh  nf  tiiiu'.  it  i.s  not  unusual  for  it  to  bocoiiio  iu- 
t"fctt't|.  and  this  int'i'dioii  may  he  with  a  simple  |iyoji:('nic  oi-jranism, 
as  tlif  stapliylocofcus.  or  with  sonu'  sucli  jit'i-ni  as  tlio  protous.  Jn 
tho  i»utrc't'activo  cases  tho  odor  is  often  hori'ilile.  In  the  former  case, 
extension  ma\-  take  jilace  and  death  result  from  menin^ritis.  The 
first  essi'Utial  in  dealing;  with  an  infection  is  to  deternnne  the  ehar- 
actei'  of  tlie  offeudinj;  or^Muisin  and  the  de|)th  of  the  infection.  In 
many  ca.ses  the  use  of  antiscplic  wet  dressinir.  1a!<in}Z  cnvv  to  use 
hut  little,  so  that  there  can  he  no  poisonin<;  from  absorption,  will 
relieve  the  trouble  foi-  the  time  beiny:.  In  other  cases  it  may  be- 
come uecessai'y  to  curctti'  and  cautei'i/.e.  or  1o  allcmpt  an  even  more 
I'adical  oi)eration.  In  still  other  ca.ses  the  u.ses  of  the  proper  vac- 
cine,   prefei-ably  autojjenous.   will   «ri-eatly  aid. 

Hemorrhage. — In  the  case  of  hennu'rhajire  it  is  sometimes  dif- 
ficult to  decide  just  what  course  to  pursue,  and  the  decision  must  bo 
made  (juickly.  The  hemorrhage  can  often  bo  temporarily  stojipcd 
])}■  ])ressure,  and  somotimos  permanently  so,  for  there  ai'o  usually 
l)roliforativo  chaufjfes  in  the  wall  of  a  blood  vessel  leading  to  an  ob- 
literating endarteritis,  before  ei'osion  actually  takes  ])laco.  As  a  gen- 
eral rule,  it  is  I'athei'  difticult  to  catch  and  lie  the  bleeding  vessel, 
for  frequently  it  is  found  that  neither  the  clamps  iioi-  ligature  will 
hold  because  of  the  diseased  condition  of  the  vessel  that  is  doing  the 
l)leeding.  In  such  cases  it  often  becomes  necessary  to  either  put  in 
a  circular  suture  or  to  cut  down  upon  the  blood  vessel  that  sup- 
plies the  part  and  tie  that.  In  the  case  of  simple  oozing,  pressure 
or  the  cautery  will  usually  suffice  to  check  the  condition. 

Invasion  of  Special  Organs. — Wlien  the  invasion  of  the  super- 
ficial or  dcei)  cancer  ])ecomos  so  groat  that  other  organs  than  the 
.skin  are  involved,  tho  prol)lom  of  the  correct  treatment  is  always 
com|>licated.  In  some  instances,  as  when  the  (irl)it  is  iiivade(l.  there 
is  always  danger  of  meningitis  developing,  and  when  the  mouth  is 
invaded  the  patient  may  starve  to  death.  Ti'oatment  in  all  such 
cases  must  l)e  according  to  tho  general  linos  of  surgery  and  modi- 
cine — at  least  give  the  patient  comfort,  and  relieve  as  far  as  possible 
all  of  the  symptoms.  Here  each  case  must  be  decided  on  its  own 
merits — no  specific  rules  can  be  laid  down. 

TREATMENT  OF  INOPERABLE  CASES. 

The  subject  of  the  treatment  of  inoperable  cases  is  not  as  pain- 
ful a  one  as  might  ayipoar.  for  much  can  fref]Uontly  be  done  for  them. 


1'ItKATMKNT.  205 

In  llic  first  ])l;i('(>,  iiuiiiy  so-c;ilIc»l  iiioiicriihlc  fjisfs  iirf  sli'ictly 
op(:r<il)l('  if  (iiic  li;is  llic  cuiirji^c  In  nii(|(il;il:c  the  ()|)cr;il  ion.  Shcr- 
woll  liiis  I  li()r()ii^'lily  (IcinonsI  t';ilc(|  I  his  in  sonic  of  liis  work.  <}\ 
course,  tlu'sc  cxiensivo  cjiiic'ci's  look  jippjiHin^'  1o  the  novice,  but  to 
the  export  thei-o  is  often  ;i  yrent  elenicnl  of  liopc,  esjiecijiUy  if  the 
tumor  be  of  Ihe  biisiil-celled  vjiricly,  jind  no  niotaHtases  nvc  io  be 
feared.  A  tlioi'ouj^'h  eurettiif^'e,  witli  excision  ol'  ;in  ;irc;i  of  skin 
around  the  edf^e,  and  tlien  tborou^^li  c;in1ci'i/,;it  ion,  will  oflcn  wor-k 
wonders,  and,  even  if  II  does  iu)t  ])ei'in;incn1 1.\  cure,  may  nmke  the 
patient  comfortable   foi-  a    nund)er  of  yc;irs   lont'^er. 

In  the  second  place,  j'adioloj^ists  ha\-e  shown  1h;d  many  of  tlie 
hopeless  cases,  even  of  a  very  malignant  type,  can  be  held  in  check 
or  rendered  comfortal)le  for  a  lonp^  period  of  time,  liadium  will  oc- 
casionally be  beneficial  even  after  the  x-rays  have  lost  their  effective- 
ness, although  this  is  not  usually  the  case. 

In  other  cases,  proper  dressing  of  the  ulcerated  areas  and  keep- 
ing them  thoroughly  clean  will  often  accomplish  brilliant  results  as 
far  as  the  comfort  of  the  patient  is  concerned. 

In  certain  cases  the  blood  vessels  supplying  the  part  can  be  ob- 
literated and  the  growth  of  the  tumor  impeded  from  lack  of  nutri- 
ment. 

And  last,  the  patient  can  always  be  kept  comfortable  by  the  use 
of  morphine  if  necessary. 

REPAIR  OF  DEFORMITIES. 

Plastic  Surg'ery. — When  a  patient  has  been  cured  of  extensive 
cancer  of  the  skin,  so  far  as  concerns  the  removal  of  the  disease, 
there  is  often  much  to  be  done  to  replace  the  deformity.  Plastic 
surgery  can  do  Avonders.  A  new  nose  can  be  built  up  from  a  finger, 
new  lips  can  be  made  from  tiaps  from  the  cheeks,  and  many  hideous 
deformities  can  be  made  much  less  noticeable  by  some  similar  means. 
This  is  not  the  proper  place  to  dwell  on  such  possibilities,  for  the 
subject  is  treated  thoroughly  in  various  text-books  on  operative  sur- 
gery. It  should,  however,  be  pointed  out  that  rio  plastic  operation 
should  be  attempted  until  the  cancer  has  been  well  for  at  least  three 
years,  as  an  operation  may  light  up  latent  cells. 

Artificial  Organs. — If  necessary,  artificial  parts  can  be  supplied 
by  various  nmnufacturers.  Artificial  ears  or  noses  can  be  procured, 
and,  Avhen  properly  tinted,  to  some  extent  are  acceptable  to  the  pa- 
tient, although  never  as  good  as  the  manufacturers  would  have  us 
believe. 

In  concluding  this  chapter,  we  must  say  that  the  time  to  treat  a 


20t)  SKIN    CANCER. 

cancer  is  in  its  early  sta^:e ;-"  if  it  be  of  the  nonnietastasizin":  type. 
eonii)lete  local  removal  will  sufiice,  but.  if  it  be  of  the  ])ricklc-cellecl 
type,  the  neighboriniir  1>  iiii>h  glands  should  be  removed  at  the  onset. 
The  one  object  in  the  treatment  of  cancer  is  to  wipe  out  every  last 
cancer  cell-^not  one  must  be  left.  To  do  this  means  the  sacrifice 
of  apparently  healthy  tissue,  and  the  surgeon  must  school  himself 
to  do  this,  making  the  question  of  deformity  an  entirely  secondary 
consideration.  It  is  l)etter  to  learn  a  few  modes  of  treatment  and 
practice  them  well  ratlier  than  to  liave  a  superficial  knowledge  of  all 
the  varieties  of  attack;  and,  above  all,  tissue  from  each  tumor  should 
be  submitted  to  competent  histological  examination,  for  in  no  other 
way  can  we  increase  our  knowledge  of  the  relationship  between  the 
pathology  nnd  llic  clinical  course  of  the  disease. 


=«Bloodgood:  Jour.  Anier.  Med.  Assn.,  1010.  Iv,  1G15. 


CHAPTER  XIX. 

TUMORS  ACCORDING  TO   LOCATION. 

Hertzler/  in  liis  ;i(|iiiii';il)lc  l)Of)k  on  limioi's,  deals  with  neoplaHms 
according  to  tlicir  location,  and  for  further  details  the  reader  is  re- 
ferred to  his  volume.  Many  of  the  epithelial  tumors,  however,  vary 
in  malignancy,  and  hence  in  their  clinical  course,  according  to  the 
region  of  the  skin  from  which  they  arise.  Also,  it  is  impossible  to 
treat  tumors  of  different  localities  in  the  same  way;  for  instance, 
one  cannot  treat  a  basal-celled  cancer  of  the  eyelid  as  he  would  a 
similar  tumor  upon  the  back. 

Scalp. — The  commonest  neAV  growths  upon  the  scalp  are  of  a 
benign  variety;  wens  or  w^arts  are  especially  common.  Malignant 
melanotic  growths  at  times  have  their  origin  here.  Cancer  of  the 
scalp  is  rather  uncommon.  According  to  Hertzler,  von  Bergmann 
found  that  out  of  675  skin  cancers  in  his  clinic,  36  had  their  origin 
in  the  scalp.  These  tumors  may  be  either  basal-celled  or  prickle- 
celled,  but  the  latter  are  probably  the  more  common.  Bloodgood 
states  that  out  of  17  epithelial  tumors,  only  6  were  basal-celled,  and 
2  of  my  own  3  cases  were  prickle-celled  in  character.  In  small  basal- 
celled  tumors,  excision  is  the  proper  course,  but  in  large  neoplasms 
it  is  justifiable  to  try  x-ray,  because  a  plastic  operation  to  repair  the 
defect  caused  by  extensive  excision  is  very  difficult.  In  the  prickle- 
celled  growths,  broad  local  excision  and  removal  of  the  neighboring 
glands  is  the  best.  Of  course,  in  this  location  block  dissection  is  im- 
possible. 

From  time  to  time  cases  of  malignant  turban  tumors  have  been  re- 
ported. While  these  were  given  various  names,  and  while  the  path- 
ological examinations  differed  somewhat,  still  all  of  these  growths 
had  many  clinical  characteristics  in  common,  and  the  name  ''endo- 
thelioma capitis"  has  been  pretty  generally  applied.  AncelP  re- 
corded a  case  occurring  in  a  26-year  old  woman,  and  which  was 
present  for  ten  years.  At  autopsy  metastases  were  found  in  the 
liver.  Four  relatives  were  similarly  affected,  but  the  disease  re- 
mained local  in  all  of  them.  Baker"  reported  another  case  in  a  man 
aged  24.     Tumors  developed  shortly  after  traumatism,  some  of  them 


^Hertzler:  Treatise  on   Tumors,   New  York,   1012. 

=  Ancell:  Quoted  by  Hoffmann  and  Friboes. 

3  Baker:   Quoted  by  Crocker.  Diseases  of  the  Skin. 

207 


208 


.SKIN    CAXCKK. 


luuk'rwent  siioutaiu'ous  involution,  liut  ono  «ji-o\v  until  it  ivaehocl  a 
(lianiotri-  of  l(t  inclu's.  whon  it  was  surjzically  roinovod  and  roiiortod 
by  the  jiatlinliiirist  tn  lu'  a  liltrosarcoiiia.  ('oiin'  i'cikii'IimI  an  instance 
in  a  woman  ajjoil  i)'2.  who  had  the  inalaily  \\)v  twenty-six  yeai's.  One 
of  her  children  had  the  same  tronlilc  Tlie  patholotrit'al  dia}j:nosis 
was  "alveolar  sarcoma  of  l>illi'<ith. ""  Ivaposi''  reiioiictl  a  case*  in  a 
man    aired    (•(>.    \vlio    had    liccn    afl'ci-tcd    foi-    \\)y\v    \cars.    and    whose 


,.:^^ 

jl4^-^7^ffTjA^n^ 

^!^%^^^M 

> 

St^^^^ 

? 

L^^^ 

jm^y^ 

V 

^^j^^/ 

"^k 

^^'    f' 

■  ^ 

/■' 

Fig.    71. — Enduthelionia   capiti.-^.      (Aftc-i-   Sijiegler.) 


daughter  had  a  similai"  condition.  Ovt)''  saw  a  case  wliidi  developed 
after  injury,  and  which  was  tlioujrht  to  he  a  si)indle-celled  sarcoma. 
Barrett'  saw  the  same  condition  in  a  mother  and  her  two  daughters. 
He  called  the  growths  "multiple  sudoi-ipei'ous  adenomata."  Spieg- 
ler''  has  carefullx-  studicil  the  condition  and  decided  tliat  the  condi- 


♦Cohn:  Jour.   Cutan.   and   flenito-Urinaiy  Di.s..   1S:>:;,   x,   V.f.i. 
'  Kapo.si:  Comptes  Renrlus  de  ConK.   Internat..   Rome.   1894,   135. 
*Oro:  Giono.  Ital.  d.  mal.  Yen.  e.  d.   Pelle.  180C,  Fas.s.   ii. 
'Barr.'tt:  Brit.  Jour.  Dermat..  Feb.   6,   1802. 
•Spiegler:  Arch.   f.   Dermat.    u    Syphil.,   1800,    1.   1G3. 


TUMORS    AC(;()KI)IN(;    TO    I-OCATIOX. 


20fi 


tion  was  really  cndotliclioiiwiloiis.  P()iif(;l''  li?]s  dcsfribod  another 
case,  calling  it  a  cylindronia  of  the  scluiccoiis  yjjinds.  IfaHlnrul"*  re- 
ported a  ease  in  wlilcli  metastases  occuiic"!.  I  lofriiKiiiti  and  P^rihoes^' 
mention  still  oilier  cases.  Lawi'cncc  lias  s(;eu  tlie  disease  in  ;i  mot  her 
and  daughter,  and  the  |);i11iological  reftort  was  endothcliojiia. 

Hoffmann  and  Frihocs  li;ive  described  a  ease  which  they  consider 
to  be  a  perfect  illustration  of  a,  ])enign  basjd-cellcid  tumor.  They  are 
inclined  to  believe  that  the  vast  m.ajority  of  these  growths  are  basal- 
celled  in  character.  Krompecher^-  agrees  in  this  view.  It  is  prob- 
able that  various  types  of  malignant  growth  can  give  a  similar  clin- 
ical picture,  and  that  treatment  must  depend  entirely  on  tbo  mifi-<-)- 
seopical  findings. 

Forehead  and  Temples. — Basal-celled  neoplasms  are  not  as  com- 
mon here  as  upon  the  face,  but  are  fairly  fi-equently  seen.     Seciue- 


Fig.    72. — Basal-celled    carcinoma    of   the   forehead.      (Heidingsf eld's    collection.) 


ira,^^  in  his  series  of  220  cases,  saw  nine  upon  the  forehead  and 
twelve  upon  the  temples.     In  commenting  on  those  of  the  forehead. 


"Poncet:  Quoted  by  Spiegler. 
^"Haslund:  Quoted  by  Hoffmann  and   Friboe-s. 

"Hoffmann  and  Friboes:  Trans.  7th  Inter.   Con.   Dermat.  e.   Syphil.,  Rome.   1012, 
931. 

Hoffmann:  Deutsch.  Med.  Wchnschr.,   1010,  2365. 

Friboes:  Beitr.    z.   Klin.    u.    Histopathol.    der   gutart.    Hautepitheliome,    Karger, 
Berlin,   1012. 

1=  Krompeeher:  Der  Basalzellenki-ebs.   Jena.   1903. 
"  Sequeira:  Brit.   Jour.   Dermat.,   1013.   xxv,   172. 


210 


SKIN    CANCER. 


he  says:  '"Here  tho  ulcers  are  usually  of  the  superficial  cicatrizing: 
type.  They  often  start  just  above  the  rot)t  of  the  nose  and  extend 
upward  in  the  frontal  region."  Crocker,  in  his  specially  illustrated 
book,  has  a  very  good  cut  of  a  case  of  this  variety. 

The  tumors  originating  U])on  the  tenijjles  seem  In  liavc  a  sj)ecial 
tendency  to  become  fungating.  Basal-celled  tumors  aiising  in  these 
localities  are  much  coimnonci-  than  tlic  itricklc-cellcd  neoplasms  (Fig. 
72  V 

Eyelids. — Basal-eelled  growtiis  are  very  ])rone  to  arise  from  the 
inner  eanthus  of  the  eye,  and  to  a  sliglitly  less  extent  from  the  outer 
canthus.  Over  thirty  of  Sequeira's  cases  had  their  origin  in  one  of 
these  locations.  Tumors  springing  from  other  portions  of  the  lids 
are  comparatively  infrequent,  but  nevertheless  do  occur,  especially 
upon   the   lowoi-  lid.     Bloodgood   says  that   out   of  twenty-four   epi- 


Fig. 


?3. — Basal-celled  cancer  of  eyelid   that   has  invaded   the  orbit. 

lection.) 


(Author's  col- 


thelial  tumors,  benign  and  malignant,  originating  upon  the  lids,  twelve 
were  of  the  basal  cellular  variety.  Hence  it  can  readily  be  seen  that 
the  vast  majority  of  malignant  tumors  arising  from  the  lids  are  not 
of  the  prickle-celled  type,  and  therefore  are  not  especially  malig- 
nant (Fig.  73). 

McDonagh'^  has  recently  Avritten  an  interesting  article  on  the  path- 
ology of  the  skin  from  the  eyelids  and  naso-faeial  gi'ooves,  and  con- 
eludes  his  article  as  follows : 

"Tumors  affecting  the  orbito-facial  and  naso-facial  grooves  are  of 
epithelial  origin,  and  atavistic  of  l)oth  the  lower  eyebrows  and  the 


"MoDonagh:   Brit.   Jour.    Dfrniat.,    iril2,   xxiv.   2'.n. 


TUMOKS  A(j(;()i{i)iN(;  TO  ]j)<:.\-i\()S. 


211 


specialized  f^larids  CniiiKl  in  IIm'sc  regions  in  iii;iMy  of  the  mammalia. 
There  is  probably  nol  ;iii  iii(li\i<lii;il  \\\\()  will  iio1  sfiow  Home  trace 
of  epith(;]in,l  eriiljryonic  tissue  (ncviis)  when  ;i  section  is  made  from 
the  skin  of  these  j?rooves.  All  the  tumors,  from  ;i,  simple  hair-fol- 
licle growth  to  a  rodent  ulcer,  ;iic  links  in  (me  fliain,  the  former 
being  the  head  oi-  most  mature,  llic  hitter  the  t;iil  or  most  embryonic. 
As  they  are  all  links,  the  hisloloj^ienl  differenees  of  one  elinie;d  en- 
tity are  at  once  explained." 

Clinically,  these  rodent  ulcers  usually  s[)re;id  r;itlier  slowly.  As 
a  general  rule,  the  mucous  itienibr;ine  is  spnred  for  some  little  time, 
but  eventually  both  it  ;iud   1lie  lachi-yinal  snc  are  invaded   and   the 


Fig.  74. — Basal-celled  cancer  of  the  nose;   a  common  location.      (Poole's  collection.) 


eyeball  destroyed,  while  the  socket  becomes  deeply  involved.  In  a 
few  instances  the  tumor  may  run  lengthwise  along  the  upper  or 
lower  lid.  Sequeira  states  that  tumors  at  the  outer  canthus  usually 
spread  downward  and  early  involve  the  bone,  but  such  has  not  been 
the  experience  of  the  author. 

These  growths  are  difficult  to  treat  for  tAvo  reasons— first,  because 
it  is  difficult  to  satisfactorily  repair  a  lid.  and,  secondly,  because  of 
the  necessity  of  not  injuring  the  eyeball.  In  the  very  early  cases 
the  writer  usually  either  excises  or  curettes  and  then  tries  the  x- 
ray.  In  later  cases  either  the  x-ray  or  an  operation  founded  on  that 
originated  by  Sherwcll  should  be  used.     In  late  cases  the  Sherwell 


'212  >lvl.N    CANCER. 

Operation''  is  undoubtedly  the  best.  Tiie  majority  of  surfjeons  and 
dermatolojrists  ajrree  with  these  conehisions,  even  the  most  enthu- 
siastic ojierators  advisiny:  x-ray  first.  Caustic  i>astes  must  never  be 
used.  l)ecause  of  tlic  itrdximily  of  the  eye,  ainl  the  iiial)ilil\-  to  cdii- 
trol  their  action. 

Nose. — Tumors  oriirinalinLr  from  the  naso-facial  iirooves  (Fiir.  74) 
arc  almost  in\iii'ial)l\'  ol"  the  l»asal-ccllc(l  tyi)c.  niid  arc  coiimioiicr 
here  than  ujHm  any  othci-  part  of  the  body.  Hh)ody:o()d"'  says:  "The 
basal-ccHcd  tumor  is  situated  most  fi('(|uently  ui>on  the  nose  (50 
percent.  l->  out  of  'J(i  cases)."  Tmnoi's  uiuui  the  ln'iduc  of  the  nose 
may  be  of  any  of  tiie  other  tyi)cs  of  cancer,  and  the  ])rickh^-celled 
variety  the  next  most  fi-e(iucntly  encountered.  It  is  usually  a  rule 
to  consider  that  all  tumors  of  the  nose  ai-e  I'odeiil  uleei's.  but  tiiis 
is  a  mistake.  A  short  time  aj^o  the  autlior  removed  from  the  l)i-i«lyre 
of  the  nose  a  small  tumor  that  had  been  ])rcsent  for  over  six  months, 
auil  was  surprised  to  find  it  to  be  a  tyi)ical  sininiiioiis-celled  carci- 
noma, h'ortunately  tumors  in  this  location  <>;row  slowly.  Because 
of  the  diftieulty  of  excising  a  jjrowth  in  one  of  the  j^i-ooves.  it  is 
better  to  use  either  the  curette  and  cau.stic  or  to  rely  on  the  x-ray. 
In  the  spinocelled  tunu)rs  it  is  imi)ossible  to  do  a  l)lock  operation. 
so  the  glands  must  be  left. 

Ears. — Two  distinct  types  of  tumoi-s  arise  trom  llu'  eai's — those 
having  their  origin  upon  the  piniur,  which  are  mostly  rodent  ulcers, 
and  those  arising  from  within  the  auditory  canal,  which  grow  very 
rapidly,  being  of  the  iiioie  malignant  type,  llcidingsfeld  has  had  a 
very  remarkable  case  where  such  a  tumor  arose  from  the  mastoid 
region  after  an  operation  for  an  infection  of  this  area.  Tumors  of 
the  i)inna  are  not  often  met;  the  author  has  seen  only  one.  and  ]^>lood- 
good  rei^oi'ts  oidy  three.  The  rodent  ulcer  variety  should  be  treated 
with  either  the  rontgen  rays  or  curette  and  cau.stic  l)ecausc  of  the 
deforniity  that  must  of  necessity  follow  an  opei'ation  with  the  knife 
alone.  The  dccji  tumoi-s  are  ])robably  hopeless  fi-om  the  stai't,  but 
radicnl  suru-(-ry   mi'z'lit   save  a   few. 

Cheeks  and  Face. — Basal-celled  tuinoi-s  here  are  comparalively 
common.  Bloodgood  has  seen  fourteen  out  of  a  total  of  fifty-five 
cases  of  benign  and  nuilignant  ei)ithclial  tumoi-s.  They  usually  arise 
about  2  cm.  below  the  eyelids,  but  may  occur  elsewhere.  Twenty- 
four  of  Sequeira's  220  cases  had  their  origin  upon  the  cheeks.  "When 
seen  early,  these  tumors  should  be  excised  and  the  scar  closed  by  a 
linear  suture;   or,  even  better,   after  excision   the   edges  should  be 


"Sherwell:  Jour.  Cutan.  Di.'<.,  1910.  xxviii,  487. 
'•Bloodgood:  Propre.'^.sive   Medicine.   Dec,    1904. 


TUMOKS    ACCOIUjINO    'I'O    LOCATION.  2]') 

c';uit(!fi/.c(l,  ;iii(l  I;i1ci'  ;i  skin  \>:n\i'\  done.  In  cxlciiHivc  casoH,  eithei' 
excision  or  ;i  Slicrwcll  (»|»('r;iti()n  ni;iy  \u'  [teffoniiefl,  or  tbo  x-ray 
or  radium  I  ricd. 

Many  of  tiu;  ]i(H)i)la.sinH  ol'  IIk;  cheeks  ;ii'(!  of  the  ni;dij;n;inl  jo'iekle- 
eelled  variety,  and  ^row  very  r;if)idly.  In  sneh  ejises  it  is  iieeossary 
1()  do  ii  \'v\'y  rjidicid  oper;!!  ion,  ini-ludin^  tlic  rcnio\;d  of  llie  neij,'li- 
borinj^-  lyinjdiaties. 

Chin. — Basai-cclled  liiniors  of  llic  fliin  arc  rare  Sequeii'a  has 
seen  only  two  such  cases.  I'riekle-eelhMl  iiuiioi's  are  also  i-arc.  Blood- 
good  has  had  two  instances  of  so-called  basal-celled  tumors  whci'C 
metastases  took  i)lacc  to  the  submental  glands,  but  is  inclined  to  re- 
gard them  as  cuboidal-celled  growths.  Excision  is  Ihe  best  treatment 
for  growtbs  in  this  locality. 

Neck. — C'onsidering  the  chi-onic  iri'itation  caused  by  collars,  can- 
cer of  the  neck  is  rare,  although  a  few. instances  do  occui-.  The  neo- 
plasms arising  in  this  locality  usually  spring  fi-oni  moles,  then  form- 
ing nevocarcinomata,  in  the  sense  of  Unna,  or  fi'om  congenital  fibro- 
epithelial  outgrowths,  then  forming  typical  rodent  ulcers,  more  rare- 
ly squamous-celled-  neoplasms.  Treatment  is  ahmg  the  lines  already 
indicated. 

Lips. — Appreciating  the  earnest  efforts  of  various  authors  and 
members  of  committees  to  educate  the  laity  and.  impress  on  the  pro- 
fession the  methods  which  should  be  adopted  to  improve  results  in 
the  treatment  of  cancer,  the  author  feels  that  he  can  best  introduce 
the  surgery  of  cancer  of  the  lips  by  calling  attention  to  certain  facts 
which  seem  of  special  moment  in  cancer  occurring  in  this  situation. 

Precancerous  Lesions. — The  surgical  importance  of  any  abnor- 
mality appearing  at  the  mucocutaneous  junction  of  the  lips,  espe- 
cially the  lower  lip,  at  middle  life  or  later,  cannot  be  too  much  em- 
phasized. If  the  lesion  persists  for  a  few  weeks  or  over  a  month, 
although  it  may  be  only  a  slight  scab  (Figs.  75,  76),  wart,  indura- 
tion, or  little  ulceration,  it  may  be  of  the  gravest  significance,  for 
this  is  exactly  the  way  that  cancer  of  the  lip  starts.  There  is  al- 
ways a  precancerous  stage,  and  this  is  the  ideal  time  for  interfer- 
ence. Bloodgood  rei)orts  cases  which  show  that  a  Avart  situated  ou 
the  lower  lip  may  become  malignant  within  two  months  after  its 
appearance.  Cancer  may  develop  in  a  pipe  burn  within  two  months, 
and  a  fully  developed  cancer  with  metastases  to  the  glands  of  the 
neck  is  possible  three  months  after  the  initial  lesion  is  noted.  The 
greatest  risk  is  in  the  cases  where  there  has  been  a  delay  of  more 
than  six  months  befoi'e  operation.     Hence  these  early  persistent  le- 


2U 


SKIN    CANCKU. 


sions  should  be  excised  with  a  inarfjfin  of  healthy  tissue;  {rcnerally 
a  small  wedjje-shaped  excision  will  suflict'.  This  sli<j;ht  operation  can 
be  easily  done  under  local  anesthesia,  and  with  little  or  no  result- 
in«i  disfifjurenient.  The  jiortion  removed  should  he  examined  by  a 
pathtil()5i:ist  accustomed  1o  differentiate  ci)ithelial  growths.  It  is  im- 
portant not  to  curi'ttc.  burn,  frci'/c.  x-iay.  or  treat  with  radium  these 
early  lesions  l)ecause.  sliouKl  one  have  alivady  taken  tm  malignant 
ehan>res,  it  could  not  be  i'ceoy:ni/.ed  until  the  patient  returned  with 
glandular  in\-olveineiit.  AVheii  the  latter  ai-e  involved,  the  oj^era- 
tion  is  a  serious  one.  anil  the  })ercentage  of  cures  is  very  much  lower 
than  in  the  early  ca.ses.     If  the  tissue  ]irove,  on  microscopical  exam- 


Pig.  75. This  patient  is  sufferirg  from  a  seborrheic  keratosis  of  the  lip.     It  would 

probably  have  become  iiuilignant  had  it  not  been  removed.     (Sutton'.s  collection.) 

ination,  to  be  cancerous,  the  cervical  lymi)h  glands  should  be  at  once 
excised. 

In  early  cases,  before  the  lymph  glands  are  involved,  we  can  hope 
to  cure  about  95  percent  of  our  cases,  but  after  involvement  of  them 
has  taken  place  the  statistics  show  about  50  percent  of  cures.  Our 
methods  are  improving,  but  two  very  vital  factors  in  future  success 
are  cai-ly  diagnosis  and  early  operation. 

Incidence. — Cancer  of  the  lips  is  comparatively  comnion  in  men 
and  very  rare  in  women,  and  usually  occurs  upon  the  lower  lip. 
Steincr^^  reports  140  cases  of  cancer  of  the  lower  lip  and  12  of  the 

»•  Stelner:  Deut.  Zeitschr.  f.  Chir.,  1009,  xcvii,  243. 


TUMORS    ACCOUDING    TO    LOCA'l'IOX. 


215 


upper,  Judd"^  Ims  Ii;ul  \^)-\  of  llic  lower  iind  only  Ihrct;  oj"  tlio  up- 
per, while  liowiil  rc(i'''  jii\c.s  llic  r;i1io  ;is  2:1 1  1o  7,  and  also  states 
that  six  times  ;i,s  nuiny  oiiifers  are  found  upon  the  side  of  the  lip 
as  upon  the  eeiiter.  IJloodj^ood 's'-"  s1;i1is1ifH  sfiow  U!l  f'f)ithelial  1u- 
mors  of  the  lower  lip  Jind  "II  of  1lic  iiiipcr  lip.  CjuK-cr  of  liie  lip 
appears  about  or  aftei-  middle  life  in  the  \;i,Ht  majority  of  iustanees 
(Fig.  77),  but  may  occjisionnlly  (|e\clo|>  in  the  younj^.  Ilertzlcr 
shows  a  marked  example  in  ;i  l)oy  of  l(i,  ;ind  llie  author  illustrates 
a  case  in  a  man  of  27  (Fifjf.  7S).  (Jancer  of  the  lip  is  mueli  nioi-e 
common  than  ])oiii^n  affections  of  Ihesc  orfrnns. 


Fig.    76. — This    man    has    a   very    extensive    seborrheic    keratosis    of    the    lower    lip. 

(Sutton's  collection.) 


Etiology. — Irritation  of  the  lips  seems  to  be  the  most  potent 
factor  in  the  etiology.  A  smoker's  burn  of  the  lower  lip  is  the 
commonest  cause  of  irritation,  but  ragged  teeth,  or  the  habit  of  bit- 
ing or  picking  the  lips  may  cause  sufficient  irritation.  Cigarette 
smoking,  where  the  paper  stuck  to  the  lips  and  left  irritation  when 
removed,  was  apparently  the  cause  of  one  cancer  under  the  writer's 
observation.  The  early  abnormality  may  be  a  slight  ulcer  or  loss 
of  epithelium,  or  there  may  be  an  epithelial  hypertrophy  and  a  re- 


isjudd:  Old  Dominion  Jour.   Med.   and   Surg.,   1908.  vii,   399. 
I'Rowntree:  Arch.  Middlesex  Hosp.,   1908,  vii.  119. 
-0  Bloodgood:  Jour.   Amer.   Med.   Assn..   1910.   Iv,   1537,   1615. 
Surg.  Gynec.  and  Obst.,  April,  1914,  404. 


:iUi 


SKIN    CANCr.R. 


sultiiiii:  wart.  Sitiue  lesions  may  i)i'rsist  as  linii^ni  Irsidiis  lor  sev- 
eral years,  and  then  tie trene rate,  but  ^enei-ally  the  i'hanf»c  is  early 
anil  (tftfU  \ri\\'   rapid,  as  lias  already  been  slateil. 

Sarcomata. — In  elassilyin*;  the  nialiirnant  tnnioi-s  oi"  the  lips,  men- 
tion must  be  made  of  sareomata.  ("ertain  of  the  an<riomata  undcrffo 
malif^nant  ehanjje.  and  must  i-eceiv(>  radical  sury:ieal  treatment, 
^lore  rarely,  snudl  round  or  spindle-celled  sarcomata  oeeur  upon  the 
lip.  !Markley-'  has  reeently  rei)orted  such  a  case  and  eollccted  sev- 
eral others  from  tlie  literature.  His  ])atient  was  65  years  of  age, 
and.  because  of  this  fact  and  because  of  the  involvenumt  of  the  eervi- 


I-^ig. 


-Ulcerated    prickle-celled    carcinoma   of  the    lower   lip   in   a   negro,    of  two 
years'    duration.      (Author's    collection.) 


cal  glands,  diaj.jnosis  of  carcinoma  was  made,  but  the  microscope 
showed  the  lesion  to  consist  of  small  round  cells,  a  typical  sarcoma 
As  the  tumor  had  been  present  for  six  months  before  radical  opera- 
tion was  done,  the  prognosis  was  naturally  bad.  These  tumors 
metastasize  early,  either  through  the  blood  stream  or  through  the 
lymphatics,  and  operation  must  be  done  very  eai-Iy  in  order  to  save 
the  ])ationt. 

Carcinomata. — The  epithelial  tumors  of  the  lip  are  the  most  im- 
portant for  our  consideration,  for  they  are  the  common  grow-ths  that 
demand  surgical  treatment.     The  lip  cancers  may  be  grouped  under 


"Markley:  Jour.    Amer.   Med.   Assn.,    lOl."?,   1x1,    r.'A. 


TUiMoits  A(.'(;()i;))iN(;  ■[(>  location.  217 

two  licadiiifijs — the  k((u;iiih)IIs-  or  prickle  (•(■lie. I  1y)H;  jind  llio  l)asal- 
ciollcd  vurjcty.  ^riic  iiialijiiuiiil  \v;irls  ;il.so  dcscrvo  r'ori.sid(!ration,  al- 
though they  arc  |»r;ic(  ic;ill\  ;il\viiy.s  pricldc celled  in  orii^dii.  This 
claHsificatioJi.  is  based  on  tiini  of  l\  roinpeclier.  'I'lie  ciibocfiljed  tu- 
mors are  Ix^st  incJiKhMJ  with  the  s(pi;inioiis-cellcd  neophisiiis,  foi'  thoy 
a.re  of  almost  sinnhir  ni;di^ii;incy,  ;iiid  hence  re(|uire  1lie  same  treat- 
ment. 

Basal-Celled  Tumors.    4:iider  the  hasal-celled  type  wc  may  clin- 
ically have  nodular  lesions,  usually  beneath  the  skin,  ulcers,  fungi. 


Fig.  78. — Prickle-celled  carcinoma  of  the  lower  lip  in  a  young  man,  which  arose 
after  treating  a  clinically  benign  lesion  with  caustic  pastes.  (Gilchrist's  col- 
lection.) 

or  warts.  The  vast  majority  of  the  so-called  rodent  ulcers  are  basal- 
celled  carcinomata,  but  occasionally  a  prickle-celled,  tumor  may  run 
a  similar  course,  differing  only  in  the  fact  that  gland  metastases  re- 
sult. Microscopically,  the  difference  is  easy  to  detect,  as  has  already 
been  sufficiently  pointed  out.  Usually  the  clinical  difficulty  in  diag- 
nosis occurs  only  in  the  very  early  cases.  The  basal-celled  growth 
has  a  greater  tendency  to  appear  as  a  subepidermal  nodule,  its 
growth  is  slow,  and  gradually  a  scab  is  formed :  the  latter  comes 
away  and  an  ulcer  appears,  or  a  fungous  growth  may  develop. 

Spinocellular  Tumors. — The  spinocellular  cancer  of  the  lip  com- 
monly starts  at  the  mucocutaneous  border,  and  the  first  symptom  is 


218 


SKIN'    CANCKH. 


an  area  of  imluration.  with  slii^ht  iik-erat'um.  I'xitli  tlu'  iiuluration 
and  the  ulceration  tcnil  \o  increase  rai>idly.  and  the  subniaxiUary 
lyini>h  «rhinds  soon  beeoine  hard  and  shot-like.  This  tjrowth  often 
has  the  appearance  of  chancre,  and  the  followin}?  are  the  chief  di- 
agnostic iH)ints.  Chancre  is  comnioii  in  the  younj;:  cancer  is  coni- 
nnm  in  the  old  and  rare  in  the  young;  cancer  is  very  rare  in  wom- 
en; chancre  equally  connnon  in  the  two  sexes;  chancre  is  almost 
as  common  upmi  llic  upi)er  lip  as  upt)n  the  lower,  whicli  is  not 
true  of  cancer;  in  chancre  the  growth  is  much  moic  i-ajiid  than 
in  cancer,  and  tiie  lymph  glands  enlarge  much  earlier;  the  spiro- 
chete   can     l»c    dcmonsti-ated    in    chancre,    and    the   histological    pic- 


Fig.   70. — Fungating   carcinoma  of  the   lower   lip,   of   only   five   weel<s'    duration. 
(C.   J.  White's  collection.) 


ture  of  the  two  is  radically  different.  A  dose  of  salvarsan  will 
cause  the  speedy  disappearance  of  a  chancre.  It  must  always  be 
remembered  that  a  chancre  will  not  give  a  positive  "Wassermann  re- 
action— at  least  not  until  late  in  its  course. 

Metastases. — As  already  pointed  out,  the  basal-celled  growths  do 
not  metastasize  to  the  lymph  glands  and  are  cured  by  a  local  opera- 
tion. On  the  other  hand,  the  commoner  prickle-celled  tumors  speed- 
ily metastasize,  and  the  presence  of  one  demands  not  only  local  re- 
moval, but  also  removal  of  the  glands  of  the  neck  becau.se  of  the 
rich  lymphatic  diainage  of  the  lips.  Of  course,  it  must  not  be  over- 
looked that  any  ulcerating  tumor  of  the  lips  may  cause  enlargement 
of  the  glands  from  simple  inflammatory    hyperplasia.      In    Blood- 


TUMORS    AC(J(J|{I)I.\(;    '1(>    LOf.'A'l'IOX. 


219 


good's  .stati.sticN  coiiccniiii}^'  iiiiiliuiiinil  liitnois  of  llic  lower  lij),  pub- 
lished in  1910,  thei-e  were  100  s(iiiioc(lliil;ii-  liimors,  2  cuboeellular 
neoplasms  (whieh  av(!  eaii  include  willi  the  preec^diiif^),  and  only  4 
hasal-ccllcd  growths.  In  eontrast,  liis  figui-es  eoneei-iiing  eancer  of 
the  upper  lip  showed  4  spino-eclled  growths  and  9  basal-celled  ones. 
In  determining  the  r('l;i1i\('  iii;ili<,ni;Mify  of  a  tumor  of  tlie  lip, 
certain  general  rules  hold  ;is  for  cpilliclijil  lumors  upon  other  poi-- 
tions  of  the  body.     Lon^'  durjilioii,  no  liislory  (»f  ;iny  active  growth, 


Fig.   80. — Fungating  cancer  of  the  lower  lip  of  five  years'  duration.     (Heidingsfeld's 

collection.) 


absence  of  enlarged  draining  glands,  tendency  to  remain  peduncu- 
lated, a  lack  of  definite  induration  at  the  base,  all  point  in  favor 
of  a  more  benign  type  of  growtli. 

Malignant  Warts. — The  malignant  Avart,  already  mentioned,  is 
a  prickle-celled  tumor.  Papillary  epithelial  tumors  may  be  malig- 
nant from  the  onset,  or  may  develop  malignancy  from  a  benign 
growth,  but,  as  a  rule,  metastases  from  these  tumors  do  not  take 
place.  Bloodgood^*^  describes  such  a  growth  springing  from  the  muco- 
cutaneous border  of  the  lower  lip  in  a  feeble  old  man,,  the  tumor 
being  of  one  year's  duration.  The  tumor  had  a  large  papillary  sur- 
face, which  overhung  normal  skin,  and  was  attached  by  a  pedicle  to 
the  edge  of  the  mucous  membrane.     There  was  no  induration  below 


!l!U 


SKIN  canci;k. 


till'  ]H'ilirlo.  Hi'cause  of  the  nhove  I'lu-ts  tlio  oporator  was  able  to 
coiu-liule  itii  (tpiM-atiun.  that  the  tunuir  was  oithoi"  l)onitrn  or  a  v(M'\ 
I'aily  papillary  (.'pithelioiiia.  L'iical  I'xcisioii  was  iH-rforincd.  and 
early  caiu'crous  chaiifjes.  liinitoil  to  tht>  wart,  wore  I'oiiiul.  Fuillior 
(•poratiitu  was  dccniod  iiiiiuH'ossary.  and  thorp  was  no  i-ccurivnco. 
Bloodgood  has  ol)si>rv(>d  st-vt-nlrrn  iiudiLiuaut  warls.  and  all  hiit  one 
has  roniaiju'd  ciiivd  hy  operation,  and  in  that  caso  the  local  incision 
was  not  sufli('ii'ntl\'  broad.  In  nine  cases  merely  a  wedtro-shai)ed  piece 
was  rcniovetl.  and  in  eitrhl  the  cer\  ical  <ilaiids  were  dissected  ont. 
In  not  a  sinjrle  instance  did  the  ^dantls  show  iiictaslases.     The  dnra- 


Fig.  81.— Prickle-celled  cancer  of  the  low  r  lip  of  light  iiKniUis'  duration,  lesion 
developing  upon  an  old  existing  fissure.  Patient  refused  operation  upon  glands 
of  the  neck  and  died  eighteen  months  later  as  the  result  of  metastases.  (Heid- 
ingsfeld's    collection.) 

tion  of  tlie  warts  liad  been:  in  two  cases,  two  months;  in  one  case, 
five  months;  in  the  remaining'  cases  more  than  six  iiK)nths,  the  lonjr- 
est  ten  years. 

Treatment. — As  has  already  been  stated,  excision  of  the  fji-owth 
with  a  good  margin  of  healthy  tissue  and  rei)air  of  the  lip — in  other 
words,  the  local  operation — is  a  justifiable  and  harmless  procedure, 
provided  the  glands  are  attacked  at  an  early  date  should  pjitliologi- 
cal  findings  make  it  necessary.  Excision  of  a  portion  of  the  tumor 
or  removal  of  a  gland  for  diagnosis  is  quite  another  matter,  and  is 


TUMORS    ACCOKDINf;    ']  (;    lAXl.VilOS. 


221 


practically  ii(!vcr  ,iii,stin;il)l(;  ihiIchh  yxti-fonncfl  on  llic  f>i)f;)'a1.int(  lablc, 
where  llie  diji^iiosis  c;ui  ]h'  iii;i(1(!  cillicr  froin  I  lie,  i^yoss  jipiK;-'i  ranee 
of  the  tissue  oi'  From  ;i  frdzcii  scdion.  ;iihI  holti  tlic  iijilicnt  ;iih1  (i]k-v- 
atof  i)re|);u'e(l  to  Jiiiiii(Mli;i,1,ely  j^o  ;ilic;i<l  willi  I  lie  complete  opfM^itioJi 
should  it  he  iiecessMiy.  It  has  been  (Iclinitdy  proven  1hjit,  if  a  can- 
cer is  cut  into  and  \vi'\,  llic  clianccs  of  snhscqucnl  furc  are  vo.ry  iriuch 
diminished.  When  a  cancer  is  incised  i'oi'  diagnostic,  j)iir[»oscH,  cer- 
tain precautions  are  nec(\ssary  1o  |irc\cn1  disscndnalion  of  cancer 
cells.  The  cut  surface  of  the  tumor  should  be  treated  with  fuii-e 
carbolic  acid,  iodine,  caustics,  or  the  actual  cautery,  drawn  tof<ether 
and  covered  with  crauzc.     All  instruments  used  in   connection  with 


Fig.  82. — Prickle-celled  cancer  of  the  lower  lip  of  fifteen  years'  duration.  Note 
resemblance  to  a  rodent  ulcer,  but  also  enlarged  glands  beneath  chin.  Cured 
for  four  years  by  radical  operation.  This  case  illustrates  the  difficulty  of  diap- 
nosing  the  difference  between  basal-  and  prickle-celled  cancer  of  the  lips. 
(Heidingsfeld's  collection.) 


the  tumor  should  be  boiled  again,  and  towels  and  gloves  changed  be- 
fore proceeding  with  the  operation. 

In  advanced  ulcerating  cases  of  cancer  it  pro1)ably  does  no  harm 
to  remove  a  portion  of  the  more  superficial  growth,  if  the  vessels 
be  scared  with  the  actual  cautery,  but.  in  general,  cutting  into  tu- 
mors for  diagnostic  purposes  is  to  be  strongly  condemned. 

Crile--  emphasized  an  important  fact  when  he  stated  that  in  a 


2=Crile:  Jour.   Amer.  Med.   Assn..   1906.   xlvii.   1780. 


---  SKIN    CANCER. 

careful  study  of  4.r)00  oases  of  cancer  of  the  head  and  neck,  ex- 
elusive  of  the  thyroid  inland,  less  than  1  i)ercent  showed  secondary 
cancer  in  distant  org:ans  and  tissues.  Death  in  these  cases  nearly 
always  results  from  the  local  or  i-cfjfional  develoi)nient  of  the  dis- 
ease. This  means  that  'Mho  collai-  of  lymphatics  of  the  neck  forms 
an  extraordinary  barrier  ihinufili  which  cancer  rarely  penetrates. 
Every  portion  of  the  barrier  is  surj^ically  accessible." 

According  to  Poirier,  C'uneo  ct  Delamere,-'^  the  lymphatics  drain- 
ing the  lips  are  generally  agreed  to  be  the  following.  There  is  a 
small  gland  in  the  cheek  situated  well  above  the  corner  of  the  mouth, 
just  above  the  fold  of  the  cheek — one  such  gland  on  each  side.    !Men- 


Fig.  83. — Piickle-ccUed  cancer  ui  ihu  uppci   lip.     (Klit  ami  Ilazon. — Courte.«y  of  the 
Journal   of   Cutaneous   Diseases.) 

tion  of  this  gland  is  not  often  found  in  the  literature,  but  the  author 
knows  of  two  or  three  cases  w^herc  it  was  per.sonally  dcmon.st rated 
to  be  involved  by  cancer,  secondary  to  cancer  of  the  upper  lip. 

The  submental  group  lies  in  a  triangle  bounded  by  the  anterior 
bellies  of  the  digastric  muscles  and  hyoid  bone ;  this  receives  ves- 
sels from  the  chin  and  central  i)ortion  of  the  lower  lip. 

The  submaxillary  group,  consisting  of  five  or  six,  or  even  more, 
glands,  lies  in  the  su])mnxillary  li-iaiiglo,  between  the  l)o]]ics  of  the 


^^  Poirier,   Cuneo   et  Dflamere:  The   LympJiatics,   1904. 


TUMOHS    ACCOKDINO    'l(;    LOCATION',  223 

dij^astric,  inusclcs  and  11k'  j;i\v,  find  dr;diis  tlic  lower  [)OftioM  of  the 
]ios(^,  th(;  clicck,  1lic  iipiicr  lip,  ;iiid  the  l;ii(i';il  [xjclion  of  the;  lower 
lip.  In  IIk;  dissection  of  lliis  j^iviiip  of  ^ihinds  ilic  l';ic]:i\  ;irtery  and 
vein  should  be  iif^atcid  a,jid  divid(!d,  IIh;  sul)rri?ixill;iry  salivary  {^larid 
should  often  be  i'(!itioved  because  of  its  close  ])i'oxiinity  to  the  lyrn- 
])hatic.  tissue,  ;iiid  \Vli;i rtmi 's  duel  slinuld  be  lied.  (Jare  should  be 
taken  not  to  injure  the  lingual  and  hyj)o«,doss;d  ju^rves,  whieh  cross 
the  floor  of  this  trianjile.  There  is  an  aiuislomosis  between  the  lym- 
phatics whieh  drain  the  two  sides  of  1hf  lip  ;iiid  also  with  thr>se 
from,  the  central  portion,  and  hence  any  bbjckinj^  of  rej^ular  drain- 
age, whether  by  cancer  or  iidlfunination,  may  cause  the  lymjth  stream 
to  flow  in  any  direction.  As  a,  result  it  is  ])est  to  remove  the  glands 
upon  both  sides  at  the  same  sitting. 

The  deep  cervical  group  of  lymph  glands  (Fig.  84),  estimated  to 
comprise  from  fifteen  to  thirty  glands,  extends  from  the  tip  of  the 
mastoid  and  posterior  belly  of  the  digastric  muscle  to  the  junction 
of  the  internal  jugular  and  subclavian  veins.  Some  of  these  glands 
lie  in  front,  but  a  larger  number  lie  behind  the  internal  jugular  vein. 
This  is  a  ver.y  important  group  in  surgery  of  the  lip,  because  it  forms 
the  second  glandular  relay  for  the  area  -which  drains  the  submental 
and  submaxillary  glands.  Consequently,  when  the  submaxillary 
glands  are  involved,  it  is  necessary  that  the  entire  deep  cervical 
group  be  removed. 

The  author  believes  that  the  ideal  treatment  of  cancer,  in  general, 
requires  that  the  primary  growth,  along  with  the  lymphatics  drain- 
ing the  part,  should  be  removed  in  one  piece ;  there  should  be  no 
division  of  lymphatics.  It  is  not,  however,  necessary  in  most  eases 
of  cancer  of  the  lower  lip  for  the  incision  for  the  removal  of  the 
glands  of  the  neck  to  be  continuous  with  the  incision  in  the  lip. 
Witness  the  cases  where  the  operation  upon  the  lip  has  been  done 
independently  of  that  on  the  neck,  and  no  appearance  of  cancer  in 
the  lymph  vessels,  which  lie  between  the  primary  growth  on  the  lip 
and  the  first  relay  of  glands  in  the  neck,  has  become  manifest. 
Beckman,-*  in  his  report  of  these  cases  from  the  Mayo  clinic,  states 
that  he  has  not  observed  a  cancer  occurring  in  the  lymphatic  vessels 
betAveen  the  original  growth  and  the  lymphatics  of  the  neck,  and 
that  cancer  of  the  lip  is  either  a  local  growth  or  a  metastasis  in  the 
adjacent  glands.  Because  of  the  danger  of  infection  from  the  buc- 
cal cavity,  it  is  of  great  importance  that  the  local  excision  and  the 
operation  on  the  neck  should  be  independent,  and  that  the  latter 
be  done  first,  although  both  should  be  performed  at  the  same  sitting. 


='Beckman:  Jour.  Oklahoma  State  Med.  Assn.,  Oct..   1913. 


224 


SKl.V    CANCKK. 


In  removing:  a  section  of  lip  wiiidi  coiitaiiis  n  basal-collod  tumor 
01*  one  of  the  inali},niant  warts,  oi-  wlien  tlie  <ri-o\vth  is  small  and  re- 
cent, and  there  is  a  reasoiuible  doiiht  that  the  1\ mitliatics  are  in- 
volvetl.  a  local  anesthetic  is  ])rel"era])le  to  a  fjeneral  anesthetic.  Co- 
caine (1  to  1,000)   with  adrenalin   (1  to  10.000)   in  normal  salt  sohi- 


Fig.  84. — This  illustration,  redrawn  after  Crile,  shows  the  relationship  of  the  deep 
lynphatics  to  the  other  structures  of  the  neck.  Note  how  closely  they  are 
associated  with  the  jugular  vein. 


tion,  or  novocainc  (^  or  ^  percent)  with  adrenalin,  arc  the  most 
easily  applied  and  the  most  satisfactory.  The  tissues  on  each  side 
of  the  growth  and  the  whole  thickness  of  the  lip  well  beyond  the 
portion  to  be  removed  should  be  thoroughly  infiltrated  with  the  solu- 
tion.    The  area  to  be  excised  should  be  outlined  by  a  gentle  scratch 


TUMORS    ACCOKDIN*;    TO    LOf.'A'I'ION.  11.) 

with  the  scalpel  l)efore  the  infill  i;i1iuii  is  hc^iin,  ;is  infill  r;i1ioii  flJH- 
torts  the  appearance  of  the  ncopljisnis  jind  rcmlcrs  i1  diffifull,  to 
recof^iiize  the  boundaries;  h(!nce  jiflcr  opci-ilinn  i1  ni;i>  he  found 
that  not  enough  margin  has  been  ^ixcn.  r.croiv  ninkin^'-  llic  inr-ision 
it  is  an  advantage  for  hemostasis  to  liavc.  Jin  ;iHsiHl;in1,  r-oni press  the 
lip  on  each  side  Ijetwcen  tliuiiil)  and  forefing(!r.  The  tissue  removed 
is  generally  in  the  shape  of  a  wedge,  with  the  apex  down  in  tumor 
of  the  lower  lip  and  apex  upward  in  the  case  of  the  upper  lip.  There 
is  a  divided  coi'onaiy  artery  to  ])e  ligalcd  on  each  side,  catgut  be- 


Fig.    85. — This   figure  and  the   following   one   show   the   common   method   of   repair- 
ing a  defect  caused  by  the  excision  of  a  V-shaped  piece  of  the  lip. 

ing  used.  Careful  approximation  of  the  skin  and  mucous  membrane 
with  linear  continuity  of  the  vermilion  border  of  the  lip  is,  of  course, 
desirable,  and  is  perhaps  best  done  with  fine  silk  or  horse  hair  for 
stitches,  using  interrupted  sutures. 

Proper  cleansing  of  the  mouth  and  teeth  1)efore  operation,  giv- 
ing special  attention  to  pyorrhea  alveolaris  (in  which  case  the  gums 
should  be  cleansed  and  swabbed  with  tincture  iodine),  are  impor- 
tant for  prompt  and  cosmetic  healing.  The  sutures  in  the  skin  had 
best  be  removed  early.  Avithin  two  or  three  days,  to  prevent  cross 


226 


SKIX    CANCER. 


scars.  TIk'  \a\vv  .spi-e;ulin«j:  of  the  woiiiul  o;in  ho  i)rcvi'iitO(l  hy  ad- 
hesive strips  across  the  wound  or  a  coHodion  dressing. 

lU^eaii.se  of  the  freciueney  of  tlie  ])rickle-eclled  eaneer,  all  sections 
thus  removed  shouM  he  exainini'd  1»\'  an  expert  i)atholop:ist,  and,  if 
found  to  be  true  eaneer,  unless  of  the  liasal-celled  ty]ie  or  of  the  non- 
intilt rating  warty  variety,  the  opei-ation  upon  llie  neck  should  be 
done  at  an  early  date. 

Various  plastic  operations  are  used  in  rejiairinj;  tiie  lip  after  the 
removal  of  a  section.     The  avoidance  of  tension  and  the  cosmetic  re- 


I 


Fig.  86.— See  Fig.  85. 


suit  should  determine  which  of  the  chiloplastics  is  to  be  used  in  a 
fjiven  case.  That  generally  used  when  a  small  lesion  has  been  ex- 
cised in  the  shape  of  a  Avedgc  is  simple  approximation  of  the  edges. 
If  the  wedge  removed  has  been  a  large  one,  and  a  great  portion  of 
the  lip  is  missing,  a  horizontal  cut  can  be  made  from  the  corner  of 
the  mouth  upon  one  or  both  sides,  carrying  the  incisions  through 
the  thickness  of  the  cheek,  and  then  the  sides  of  the  wedge  drawn 
together  without  tension  (Figs.  85,  86).  ]\Iayo's  method  of  remov- 
ing a  quadrilateral  section  instead  of  a  wedge  is  an  improvement 
(Figs.  87,  88).  In  extensive  growths,  Avhich  have  invaded  the  lip 
or  cheek  extensivelv.  there  can  be  no  hard  and  fast  rules  for  the 


TUiMOns  ACCOinx.Nw;  ro  i.ocatkjn'. 


227 


ehiloplasty  (J^'i^s.  S!),  !)0,  !)l).  I1  is  mosl,  impoi  1;iii1  1o  »/ivf  Ihf 
growth  a  wide  iiiai'i^in  ;iiiil  nol  siicrilifc  coiiiiilcfc  rcuKJVJil  1o  Ific  rlr;- 
Kire  for  an  cany  closure 

As  has  l)(M.'ii  s;ii(|  iihovc,  llicrc  slioiiM  ])vc\'cvi\\)\y  lie  no  cowdcc^jou 
between  the  lines  ol"  incision  i'nr  removal  of  a  growl h  on  the  11  f> 
and  the  incision  on  the  neck  Jor  llic  removal  of  the  lymf»hatics.  The 
older  ingenious  plastics,  which  combined  (hips  i'oi'  1lie  closun;  of  gaps 
in  the  lij)  and  exposure  of  field  for  )'(;iiiovi)ig  cei'vical  lymithaties, 
are  obviously  not  to  ])v  reconunended — first,  ])ccHnsc  of  the  risk  of 
infecting  the  entire  field  of  operation  from  the  buccal  cavity,  and, 
second,  because  the  operation  upon  the  cervical  lymfth  glands  can- 
not be  complete  enough. 

In  the  hands  of  those  expert  enough  in  the  use  of  local  anesthetics, 
especially  novocaine,  extensive  o])crations  can  be  done  upon  the  neck 


Fig.    87. — This   shows  the   incisions  used  at   the   Mayo   clinic,   both   for  the   removal 
of  the  growth  and  the  repair  of  the  deformity.     (Redrawn  after  Boeckman.) 

very  satisfactorily  without  submitting  the  patient  to  the  risk  of  a 
general  anesthetic.  The  majority  of  surgeons,  however,  still  prefer 
a  general  anesthetic  for  this  part  of  the  w^ork.  If  the  lip  is  done 
first,  the  gloves  should  be  changed  and  fresh  instruments  and  towels 
used  for  the  second  part  of  the  operation  upon  the  neck.  It  is  gen- 
erallj''  advantageous  to  do  the  radical  operation  upon  the  neck  first, 
and,  after  the  neck  incisions  have  been  closed  and  protected,  excise 
the  portion  of  the  lip  containing  the  growth  and  repair  the  lip. 

Extensive  operations  for  cancer  of  the  lip,  as  for  cancer  else- 
where— often  in  old  men  Avith  arterial,  renal,  or  myocardial  changes 
— should  never  be  undertaken  without  previous  most  careful  exam- 
ination of  the  patient's  general  condition  and  preliminary  treatment 
according  to  the  demands  of  the  system. 

The  avoidance  of  shock,  hemorrhage,  and  infection  is  especially 
necessary  in  these  cases.    A  preliminary  dose  of  morphine  and  atro- 


22S 


SKIN    CANCKR. 


I»ino.  a  carofully  '^Won  anostlit'tic  a  iiiiniiiiuin  of  Irauinn  from  re- 
traction ami  throat  dissection,  will  lessen  the  shock.  The  exclusion 
of  nervous  stimuli.  accordin«:f  to  Ci-ile's  ])rinciple  of  anoci-assoeia- 
tion.  is  an  imi)ortant  refinement  in  pi-cventing  shock  in  weak  or  ner- 
vous individuals.  The  most  ])ainstakin<ir  liemostasis  is  desirable, 
not  only  to  avt)id  loss  of  blood,  but  so  that  structures  may  be  more 
easily  reeojinized  dui-iny:  the  opci-atiou. 

The  importance  of  makinj;  the  o])cration  upon  the  neck  independ- 
ent of  that  on  the  lip,  to  avoid  infection,  lias  been  mentioned.     ^Vhcn 


^ 


Fig. 


. — At  the   Mayo  clinic  the  deformity  caused  by   the  excision  of  a  cancer  of 
the   lip   is   remedied   as   shown   above.      (Redrawn   after   Boeckman.) 


Wharton's  duet  is  divided  for  removal  of  the  submaxillary  salivary 
gland,  there  is  always  a  slight  risk  of  infection  from  the  mouth. 

To  avoid  dissemination,  the  carcinomatous  tissue  should  be  han- 
dled carefully  and  not  clamped  or  squeezed.  The  dissection  must 
go  beyond  the  tissues  known  to  be  infected ;  incomplete  operations 
are  worse  than  no  operations.  Inoperable  cases  are  those  in  which 
the  cancer  has  left  the  glands  and  invaded  the  deep  planes  of  the 
neck.  The  skin  may  be  adherent  or  encrusted  over  the  submaxillary 
glands,  and  still  the  case  be  perfectly  oi)ei'able. 


TUMORS    ACCORI)rN<^;    TO    I/M'A'IION-. 


220 


Beckinun,  vvrilin^'  from  llu;  Mayo  r-liiilf,  sjiys  tlml  llifir  pi-f't'crftKio 
in  CHseH  where  it.  is  iieccssjiry  to  cju'ry  IIk;  disscr-lioii  flown  1o  the 
cljivif'lc  is  to  do  the  opcivition  in  two  stjij^'cs.  The;  iicfk  is  done  first, 
and  tlie  j)i'im;uy  jj;'ro\v11i  on  llic  ii|)s  one  week  i;i1ci-.  An  ineision 
is  made  about  thr(H'-(|u;ir1(!rs  of  ;in  ineh  hclow  Ihe  I'Jiinus  of  the 
jaw  and  extendi]!^  IIii-ouhIi  si\in  nnd  pljitystini  from  ()])('.  stfrnomas- 
toid  to  the  other.  T\n\  low  incision  ;ivoids  Hie  snudl  hrjuK-li  df  1ho 
f;iei;i,l  artery,  which  innervates  the  muscles  about  th(;  ;int;le  of  the 
mouth.  All  of  the  f;isci;i,  and  fat,  includinjjj  the;  submaxillary  sali- 
vary glands,  arc  removed,  and  lluis  bolh  submaxillary  triangles  and 
the  sn])menta1  ti-iangle  are  einplied.     The  glands  from  the  su])maxil- 


¥■■ 


■3 
/ 


it- 


Fig.   89. — Pigs.  89,  90,  and  91  illustrate  various  plastic  operations  for  repairing  de- 
fects after  removal  of  cancer  of  the   lip.      (Redrawn  after   Tilton.) 


lary  triangle  on  the  side  of  the  tumor  are  examined  at  once,  and, 
if  they  are  found  to  be  carcinomatous,  the  incision  is  carried  down 
to  the  clavicle  on  that  side.  All  glands,  including  the  anterior  and 
posterior  jugular  groups  on  this  side  of  the  neck,  are  removed  by 
block  dissection.  If  the  glands  in  the  submaxillary  region  on  the 
side  of  the  neck  opposite  the  tumor  be  also  involved,  nothing  short 
of  a  block  dissection  of  both  sides  of  the  neck  is  permissible.  There 
were  ninety-nine  patients  who  had  a  primary  radical  operation  done 
for  cancer  of  the  lower  lip- — that  is.  both  the  glands  of  the  neck  and 


230 


■  KIN    r\.\ri:iv 


the  growth  excised,  rures  wore  ostiniatod  ;it  S3. 8  percent;  thirty- 
nine  of  these  patients  IkuI  fjrone  tluve  years  since  ojicration  and  four 
over  five  years.  In  eijjhteen  cases  out  of  the  ninety-live,  carcinoma 
was  demonstrated  in  the  trlands  by  tlie  niici'(»sct»])e  at  the  time  of 
operation.  Of  these  nine  or  .')()  percent  weiv  amon}f  tlie  cured  eases. 
In  a  };roup  wliere  some  ]>i-evious  (i])eration  had  been  done  upon  tlie 
lip,  or  it  hatl  been  ti'cated  with  a  caustic  jiaste.  and  a  late  radical 
operation  was  ])ei-foi-nu'd.  the  cures  were  TO  ]iercent.  Of  this  lat- 
ter grou])  showing  ^Handular  involvement.  33  1  '3  percent  were  cured. 
Crile  stniiiLrly  ui'<;es  the  iieclv  (ii»eratinu  as  a   I'outine  in  all   eases 


Fig.   90.— Set-  Fig.    89. 


of  cancer  of  the  lip.  Where  there  ai'c  no  pali)al)le  glands,  he  makes 
the  small  incision  as  illustrated  in  Fig.  92.  Thi-ough  this  the  re- 
gional lymphatic-bearing  tissue  is  removed  by  block  dissection.  This 
includes  both  fat  and  glands  of  the  submental  and  sulnnaxillai-y 
region  on  the  side  of  the  growth.  The  submaxillary  salivary  gland 
is  not  removed  if  there  is  certainly  no  in\(»lvement  of  the  regional 
lymjdiatics.  In  cases  with  definitely  involved  enlai'ged  lymphatic 
glands  the  entire  lymphatic-bearing  tissue  of  that  side  of  the  neck 
is  removed.  The  carotid  ai-tery  is  exposed  as  low  down  as  possible 
by   an    intramusculai-   se])aration    of   the   stei'nomastoid    muscle,    and 


TIJM(M{S    A(;C0I{1>IN(;    '10    l-OCA'IION.  2'',] 

tornporary  closure  of  1liis  ;i fiery  is  en'ccicd.  The  eoriiplele  skin  in- 
cision (Fi^.  9'>)  is  llieii  Jiiade  (iiKiliidinu  phil  \'sm;i  j  and  the  flaps 
extensively  reflected.  The  sternomastoid  is  disided,  llic  external  and 
internal  jufi'uliir  v(!ins  are  secured,  douMy  lied,  ;iiid  divided  at  the 
base  of  the  U(U'i\.  The  dissection  is  Ihen  f';iri'i(;(l  from  helow  u[)\vard 
(Fif^^s.  94,  95)  into  the  de<!p  pljines  of  the  neck,  l)ehin<l  1he  lymph 
glaiuls.  All  the  fat,  f;isei;i,  nmseles,  veins,  and  connective  tissue  ai-c 
carried  upward.  The  dissection  beconies  ensy  wheu  following?  the 
deep  plane.  The  entii'c  block  of  tissue  is  finnlly  dixided  nbove  (Fig. 
90).  It  includes  fascia,  fat,  submaxillary,  salivary  and  part  of  the 
parotid    j^lands,    sternomastoid,    omohyoid,   pni-t   of  the  stylolingoid 


Fig.   01.— See   Fig.   SO. 

muscles,  the  entire  venous  system.,  and  all  the  lymphatic  vessels  and 
glands  in  this  region.  The  key  to  the  situation  in  the  radical  block 
excision  of  the  entire  side  of  the  neck  lies  in  the  removal  of  the 
internal  jugular  vein.  Crile  has  done  this  radical  operation  on  both 
sides  of  the  neck  in  the  same  individual  in  two  operations,  with  an 
interval  of  three  months  between  operations.  Both  the  internal  and 
external  jugulars  Avere  removed  on  both  sides. 

Crile 's  radical  block  dissection  has  shown  itself  to  be  four  times 
more  effective  than  his  former  procedures. 

Bloodgood  urges  sursreons  to  studv  their  cases  of  cancer  of  the 


2'V2  SKIN    CANCER. 

lower  lip  in  which  the  ijhiiicls  show  inetastnsis.  11  is  oases  showed 
only  50  percent  of  tive-year  cures.  He  does  not  think  that  the  opera- 
tion on  glands  has  been  complete  enough,  and  believes  that  a  por- 
tion of  the  parotid  and  the  snl)inaxillary  salivary  glands  should  be 
included  in  the  block.  The  subparotid  lymiili  glands  have  been  left 
behind  in  recent  operations,  for  he  feels  that  it  is  impossible  to  com- 
pletely remove  these  glands  without  the  ligation  and  excision  of  the 
upper  poi'tion  of  the  internal  jugular  l)ohind  which  they  lie.     The 


Fig.  92. — When  the  glands  are  not  palpably  involved,  this  incision  should  be  made. 

(Redrawn    after   Crile.) 


operation  for  recurrent  cancer  of  the  lij)  i-cduccs  the  probability  of 
a  cure  at  least  42  percent. 

In  cases  of  cancer  of  the  upper  lip  the  simple  local  operation  can 
be  more  often  done,  because  the  majority  of  cancers  here  are  of  the 
basal-celled  variety.  When  a  prickle-celled  tumor  is,  however,  sit- 
uated on  the  up]K'r  lip,  the  same  operation  is  indicated  as  for  can- 
cer of  the  lower  lip. 

Conclusions. — In  conclusion,  it  must  be  said  that  cancer  of  the 
lip  is  a  serious  and  freriuent  malady,  and  that  it  may  develop  with- 
in two  months  after  the  onset  of  an  apparently  simple  malady.  Be- 
nign and  precancerous  lesions  occurring  here  shf)uld  1)0  excised  early 


TUMORS    A(J(J(>KI)IN(J    'I'O    IA)(:.\-\\()S.  S-)'-> 

and  histologically  cxainincd  in  mnkf!  sure  of  their  cli;) rafter.  None 
of  the  lesions  should  be  tr-cnlcd  Mk;  way  skin  lesions  may  bo  treated 
— that  is,  by  eansties,  eautery,  ejirbon-dioxide  snow,  x-ray,  radium, 
etc.  The  rarer  l)iis;il-eelle(l  liinMirs  :\\\<\  the  ni;ili!jn;iii1  warts  do  not 
require  more  tluui  a,  careful  locjil  exeision. 

All  squaiiious-eelled  eaueers  should  hnve  not  <)r\]y  local  removal, 
but  also  removjil  of  the  ;Ul;inds  of  the  neck. 

The  local  o[)era1ion  e;in   rejidily  be  done  witli  loejil  anesthesia,  and 


Fig.    93. — When    the    glands    are    clearly    involved,    this    incision    should    be    made. 

(Redrawn  after  Crile. ) 


under  proper  conditions  the  radical  operation  can  be  performed  in 
the  same  way. 

The  slight  tendency  for  the  growth  to  go  beyond  the  cervical 
lymph  glands  and  the  accessibility  of  these  glands  should  encour- 
age more  radical  and  painstaking  operations. 

Where  the  submaxillary  glands  are  known  to  be  definitely  involved, 
the  entire  lymphatic  chain  on  that  side  of  the  neck  should  be  removed 
by  block  dissection,  including  the  internal  jugular  vein. 

Tongue. — Like  all  other  cancers  of  the  skin  and  mucous  membranes, 
carcinomata  of  the  tongue  do  not  arise  de  novo,  but  from  some  pre- 
existing lesion.     There  is  first  an  ulcer  or  a  little  area  of  infiltration 


234 


SKIN    CANCER. 


that  should  «rivo  i>kMity  of  warniniyr.  Tlieso  precancerous  lesions  may 
arise  in  various  ways;  they  may  be  due  to  the  irritation  caused  by 
bad  teeth,  or  they  may  result  from  tlie  excessive  use  of  tobacco,  either 
smoked  or  chewed.  The  latter  must  jday  some  part,  for  cancer  of 
this  or^an   is-  very  rare  in  women.     ShimII   ]>apill;iry  outsjrowths  of 


«*,V.;''-^vv'^''V 


\ 


/ 

Fig.  ;'4. — After  the  skin  and  i!Ubcutaneou.s  ti.-!sue  have  been  inci.sed,  the  stor- 
nocleidonia.stoid  muscle  is  divided,  the  jugular  veins  ligated  and  cut,  and  the 
carotid  artery  is  clamped.  The  skin  and  plat.vsma  are  then  dissected  back. 
(Redrawn  after  Crile.) 


the  tip  or  tlie  latci'nl  ed<res  of  the  tonj^ue  arc  rather  infrequent,  but 
nevertheless  do  occu)-,  and,  even  where  there  is  no  deep  infiltration, 
they  should  always  be  removed,  preferably  Avith  the  electric  cautery. 
Syi)hilis  is  probably  the  most  frequent  cause  of  cancer  of  the 
tongue.     Syphilis  may  produce    either    ulcers    or    superficial    over- 


TrjMOKS  A(;(;()i;!)i.\(;   'kj  location. 


growths,  ;ui(l  these  are  vc.vy  ;ip1  1o  iiii(|ci';_"i  iii;ili;.'ii;iiit  fhimge,  espe- 
cially in  heavy  smokei-s.  'I'lic  well  Iwiow  n  Iciikdplakia,  tlie  80-callcd 
psoriasis  or  smoker's  [latdi  o\'  llic  lon^iic,  is  oflcri  due  to  Hyphilis, 
although  the  use  of  lohacco  nnisi  play  a  wvy  iinporJaiit  ftart.     This 


Fig.  95. — The  entire  mass  of  lymph  g-land-bearing  tissue  is  ilieii  excised  en  bloc. 
The  dissection  must  be  done  in  the  deep  plane  of  the  neck.  (Redrawn  after 
Crile.) 


ailment  is  characterized  by  the  presence  of  superficial,  white,  slight- 
ly indurated  patches,  that  have  a  tendency  to  form  deep  cracks  and 
fissures.  ]Many  of  them  subsequently  degenerate  into  true  cancer. 
"When  leukoplakia  is  first  seen,  a  thorough  search  for  syphilis  should 


23G 


SKIN    CAXCER. 


always  ho  instituted,  and,  if  that  is  pi-osont.  aiitisyi)hilitio  medica- 
tion should  1)0  i)Ushod  :  in  addition,  sniokiny:  must  bo  absolutely  pro- 
hibited. Tf  syphilis  bo  not  jH-osent.  snit)kin«r  should  bo  forbidden  and 
mild  mouth  wash  i)rosori])od.     If  the  losious  yield  jjioinptly,  as  they 


Fig.   96. — All  gland-bearing  tissue  has   been   removed,   and   the  wound   is   ready   to 
be   closed.      (Redrawn   after  Crile.) 


sometimes  do,  operative  treatment  is  not  necessary,  but,  if  the  le- 
sions still  persist  and  especially  if  they  increase  in  size,  they  should 
be  thoroughly  removed,  preferably  by  either  the  actual  or  the  elec- 
tric cautery.  In  no  case  should  they  be  touched  with  mild  caustics 
or  with  any  irritating  substances;  this  is  the  worst  thinj?  that  could 


TUMORS    ACA'OHDl  SC,    TO    1,00A'I'I0N.  2'',~ 

possibly  ])(!  done,  For  ;iiiy  fonii  of  irriliil  ion,  sliorl  di'  foiiifdflf,  re- 
moval, may  Hiimulato  eaiiccrous  (diaiijics. 

Tuberculous  ulcers  may  likewise  become  caiic,(;i(Hi.s,  but,  as  a  k'""- 
cral  rule,  tuberculous  lesions  arc  rare,  except  in  advanced  tubercu- 
losis of  the  luuf^s  or  in  a  ^fciicralizcd  liihcffulosis. 

Any  crack,  fissure,  or  nodule  shtjuld  be  viewed  with  suspicion  un- 
til it  is  proven  not  to  be  cancerous.  There  are,  of  course,  a  number 
of  lesions  of  the  tongue  that  are  perfectly  benign ;  such  a  one  is 
lichen  i)lanus,  which  often  involves  the  mucous  membranes  of  the 
cheek  and  which  may  invade  the  tongue.  Occasionally  we  find  a 
superficial  infiltration  of  the  surface,  an  infiltration  that  is  sharp- 
ly localized  and  rather  angular,  and  that  is  most  apt  to  occur  in 
those  who  use  either  tobacco  or  snuff,  and  which  seems  to  remain 
harmless.  But  in  all  cases  of  any  alniormality  a  skilled  man  should 
be  consulted. 

Varieties. — Various  types  of  cancer  may  occur  upon  the  tongue, 
but  the  common  one  is  the  spino-celled  carcinoma,  the  type  that 
speedily  metastasizes.  Cubo-celled  gi'OAvths  also  occur,  but  they  are 
of  mere  pathological  interest,  for  they  are  nearly  as  deadly  as  is 
the  type  just  mentioned.  The  spino-celled  wart  also  rarely  occurs 
here;  fortunately  it  does  not  metastasize,  so  local  removal  will  suf- 
fice to  give  a  cure.  Basal-celled,  cancer,  and  rodent  ulcers  are  ex- 
tremely rare,  and  such  a  diagnosis  should  be  received  Avith  the  great- 
est caution.  The  pathology  of  all  of  these  growths  is  identical  with 
that  of  those  already  described. 

Symptomatology. — Cancer  may  develop  upon  any  part  of  the 
tongue,  but  usually  upon  the  dorsum  near  the  edge,  this  being  the 
part  most  exposed  to  trauma.  Occasionally  they  develop  primarily 
upon  the  floor  of  the  mouth.  As  already  indicated,  there  is  always 
a  precancerous  lesion;  it  is  noted  that  either  deep  induration  or  ul- 
ceration, or  both,  has  taken  place  around  this,  and  that  an  indurated 
ulcer,  rarely  a  fungous  tumor,  results.  Glandular  involvement  may 
occur  within  one  month,  and  is  rarely  postponed  more  than  six 
months.  The  floor  of  the  mouth  is  often  infiltrated  at  a  very  early 
date,  nearh'  always  Avithin  six  months. 

Diagnosis. — The  first  difficulty  is  to  determine  -whether  a  pre- 
cancerous lesion  has  actually  taken  on  a  cancerous  change,  and  how 
long  this  change  has  existed ;  this  is  always  extremely  difficult,  for 
it  is  much  easier  to  diagnose  a  late  cancer  than  it  is  an  early  cancer, 
the  only  trouble  being  that,  when  a  carcinoma  is  easily  diagnosed, 
it  is  not  easilv  cured.    Hence  there  is  onlv  one  safe  rule,  and  that  is 


238 


SKIX    CANCER. 


to  treat  all  such  k'sions  as  early  cancers,  and  to  Ikinc  live  jKitients 
at  the  eml  of  a  few  years.  In  eertaiii  instances  it  is  almost  impos- 
sible to  distinguish  a  jijummatous  lesion  from  a  cancer.  AVhen  one 
remembers  that  cancer  so  freciiiently  develops  upon  a  syphilitic  basis, 
it  can  be  readily  seen  that  the  AVassermann  reaction  is  more  apt  to 
prove  a  hindrance  rather  tlian  an  aid.  In  case  of  doubt,  and  if  the 
lesion  is  advanced,   it    is  wt'll   to  ";ive  two  or  more  intravenous  in- 


Fig.  97. — This  cancer  of  the  tongue  is  of  four  months'  duration.  It  had  been 
treated  with  various  caustics,  which  had  apparently  hastened  its  growth. 
(Photograph  by  Dr.   Walter  Van   Swerirgen  of  Dr.  H.   H.   Kerr's  patient.) 

jections  of  salvarsan  at  close  intervals  and  watch  the  result.  In  the 
case  of  a  small  lesion  the  same  procedure  may  be  tried,  or  the  whole 
lesion  may  be  excised  with  the  cautery  and  then  studied  microscopi- 
cally. Tuberculous  lesions  may  also  ])c  difficult  to  distinguish.  In 
the  case  of  very  advanced  tuberculosis  it  makes  vei-y  little  difference 
what  the  lesion  is,  but  in  other  cases  the  differential  diagnosis  may 
be  a  matter  of  extreme  importance.  The  whole  lesion  should  be  ex- 
cised with  the  cauteiy,  and  the  centi-al  portion  sludiod  microscopical- 


TUMORS    ACCOUDWC,    'If)    \.()CA'[l()S.  230 

ly  and  a  Ijit  of  llic  frcsli  tissue  iiijccicd  into  ;i  ^iiinc;!  \}\rr.  This  last 
is  iinportaiit,  because  1  iihcrciilosis  iii;i>  liisldln^Mfjilly  r(;S(;rn}>]c  r-ar- 
ciiioina. 

Treatment,  liloodij'ood-''^'  liiis  fcccntly  wrillfii  .-i  short,  but  stim- 
ulating, article  on  1  re;il  iiienl  of  e;ine(-i'  of  the  tnn^iie.  lie  states  that 
in  the  very  early  cases — th;it  is,  where  ni;ili<^ni;in1  ch;in^'e  is  just  tak- 
ing place —  a  complete  local  removiil  with  the  c;iu1ery  will  nf;arly 
always  effect  a  cure.     Iieferrin^'  to  the  ];iter  e;ises,  iJloorJgood  states: 

■  "It  has  been  demonstrated  that  the  failure  to  eui'e  when  the  can- 
cer of  the  tongue  is  fully  developed  is  due  to  the  neglect  to  remove 
the  muscles  of  the  floor  of  the  mouth  below  the  cancer. 

"The  high  mortality  after  operations  for  cancer  of  the  tongue  is 
chiefly  due  to  the  removal  of  the  floor  of  the  mouth  without  re- 
moving at  the  same  time  a  section  of  the  lower  jaw. 

"When  the  operation  is  performed  in  one  stage,  it  is  impossible 
to  remove  the  tongue,  the  floor  of  the  mouth,  the  glands,  and  then 
close  the  opening  in  the  mouth  unless  a  section  of  the  lower  jaw  is 
also  removed.  If  the  former  operation  is  done  thoroughly,  the  mor- 
tality is  very  high — almost  80  percent — from  i)rimary  or  secondary 
pneumonia,  or  late  infection  from  the  oral  fistula." 

For  moderately  early  cases  Bloodgood  recommends  an  operation 
done  along  the  following  lines:  The  glands  of  the  neck  are  first 
thoroughly  removed,  and  the  floor  of  the  mouth  above  the  glands, 
but  below  the  tongue,  thoroughly  burned  with  the  cautery,  and  the 
wound  closed.  At  a  little  later  date  the  affected  portion  of  the  ton- 
gue and  the  floor  of  the  mouth  below  it  are  attacked  from  above 
with  the  cautery  until  the  two  areas  of  cauterization  meet.  The 
healed  skin  flap  from  the  first  operation  forms  the  floor  of  the  mouth 
and  prevents  infection  from  without. 

In  very  late  cases  it  is  still  necessary  to  remove  a  section  of  jaw, 
the  tongue,  floor  of  the  mouth,  and  glands  in  a  block  operation. 

Trunk, — Cancer  of  the  trunk  is  rather  uncommon,  although  the 
most  frequent  site  is  around  the  shoulders.  In  this  locality  the  ma- 
jority of  growths  are  of  basal-celled  origin,  and  do  not  metastasize. 
Upon  other  portions  of  the  body  prickle-celled  growths  predominate, 
and  they  should  always  be  removed,  together  with  the  draining 
glands,  by  a  block  operation,  as  otherwise  recurrence  is  very  apt  to 
follow. 

About  the  breast  we  may  find  Paget  "s  disease  of  the  nipple  or  a 


"Bloodgood:  South.  Med.  Jour.   1914,   vii,   542. 


'24V  SKIN    CAXCKR. 

carcinoma  tn  cuirussc.  The  latt(M-  is  very  rare,  l)iit  must  be  thought 
of  when  nodules  appear  upon  the  skin  in  the  Aicinity  of  the  mam- 
mary ffland. 

Extremities. — Tlie  following  account  is  from  a  i-ecent  article  by 
the  author.-" 

Because  of  the  failure  to  distinguish  between  the  various  tyjies  of 
cutaneous  cancer,  many  of  the  older  articles  on  carcinoma  of  the 
extremities  are  practically  worthless  from  a  modern  point  of  view. 
Howard  Fox-"  has  recently  rejiortcd  an  intei-esting  case  of  cancer 
of  the  hand  which  metastasized  to  the  mediastinal  glands,  and  has 
reviewed  the  literature.  After  studying  various  articles,  notably 
those  by  Hcimann,-^  Gurlt.-"  von  "Winiwarter,^"  Neumann, ^^  Bulkley 
and  Janeway,''-  von  Brunn,^^  Volkmann,^'*  and  Franz""'  he  comes  to 
the  conclusion  that  cancer  of  tlu'  limbs  is  (Mniiparativi'ly  a  rare  dis- 
ease as  compared  with  cutaneous  cancer  in  other  jiortions  of  the 
body.  Fox,  referring  to  cancer  of  the  hand,  further  says:  "In  spite 
of  the  malignancy  of  these  cases  from  a  microscopical  standpoint, 
there  can  be  no  doubt  that  clinically  they  are  relatively  benign,  gen- 
erally running  a  slow  course,  and  only  late,  if  at  all,  invading  the 
hTTiphatic  glands."  On  the  other  hand,  in  a  discu.ssion^"  of  this 
paper,  both  Schalek  and  Corlett  rei)orted  cases  in  which  metastases 
had  occurred,  while  "Wile  called  attention  to  the  fact  that  cancers 
originating  in  arsenical  keratoses  usually  metastasized. 

Bloodgood^'  has  consistently  contended  that  the  lymphatic  glands 
should  be  removed  in  all  cases  of  prickle-celled  cancer  of  the  body, 
no  matter  where  located,  but  especially  on  the  limbs,  for  here  is  it 
always  easy  to  remove  the  draining  lymphatics.  Steiner,^^  writing 
from  the  clinic  of  Dollinger,  states  that  a  routine  practice  is  made 
of  removing  lymi)h  glands  in  all  cases  of  cancer  of  the  extremities. 
A  summary  of  the  literature  would  seem  to  indicate  that  cutaneous 
cancers  of  the  extremities  are  not  especially  common,  that  they  are 


*«Hazeii:  Jour.   Amer.   Med.  Assn..   1915,   Ixv.  837. 
''Fox:  Jour.   Cutan.   Dis.,    1015,   xxxii.   22. 
^Heimarn:  Arch.   f.   klin.    Chir.,  1898.   Ivii,   911. 
»Gurlt:  Arch.  f.  klin.  Chir.,  1880.  xxv,  421. 

"von  Winiwarter:  Beitrage  zur  Stati.stik  der  Carcinome,  Stuttgart.   1878. 
•'Neumann;  Bcitrag    zur    Kenntnis    der   Extrcniitaten-Krebse    im    Anschluss    an 
zwei  Falle  der  Freiburger  Klinik,  Inaug.  Diss.  Freiburg  im  Breisgau,   1911. 
"Bulkier  and  Janeway:  Med.   Record,  New  York,  Ixiii,  465. 
"Von  Brunn:  Beitr.  z.   klin.  Chir.,   190.3,  xxxvii.  227. 
"Volkmann:  Samml.  klin.   Vortr.,  1889.   No.   102. 
"Franz:  Beitr.    z.   klin.   Chir.,    1902,   xxxv,    171. 
'•Discussion:  Jour.   Cutan.   Dis.,   1915,  xxxiii,   29. 
"Bloodgood:  Progressive  Medicine.  Dec.  1004.  1907,  1908.  1912. 
"  Steiner:  Deutsch.    Ztschr.    f.    Chir.,    1906,    Ixxxii,    363. 


TtlMOKS    A(J(,MJin)lN<;    'l(>    I.Of.'A'l'ION.  2-11 

more  common  on  the  lower  th;iii  on  Ihe  ujtjjer-  limits,  that  they  al- 
ways follow  some  ])i'(!('aneei'ous  coiMlilions,  th;i,t  Ihoy  are  usually  of 
the  prickic-cclhul  lypc,  thiii  tlu^y  Jii-e  j-;ire  on  tlic  [uilins  (jf  the  hands, 
and  thai  wiien  occii yy\\\<j;  on  1h(!  b;ieks  of  the  h;inrjs  they  are  relative- 
ly benifjjn.  Iv'e^ardin^  llicir  lendcaiey  to  form  metastases,  there  is 
considerables  divcrsily  of  opinion. 

With  a  view  of  clearin;^'  up  the  last  j)oint,  Avhieh  is  of  f^reat  yjrac- 
ticid  importance,  espccinllx'  now  that  radium,  the  Kiintji^en  rays,  ful- 
^'uration,  (h'siccat  ion,  and  similar  nonoiicral  i\c  jn'ocedurcs  are  mak- 
ing' j^i'cat  l)ids  for  the  treatment  of  these  conditions,  the  author  pre- 
sents the  statistics  shown  in  table  2,  dei-ived  largely  fi'om  Dr.  Blood- 
flood's  surgical-pathologic  laboratory  of  the  Johns  Hopkins  Hospital, 
from  the  surgical  wards  of  the  Frcedmcn's  Hospital,  and  from  the 
writer's  practice. 

TABLE    1. — DISTRIBUTION    ON    UPPER    AND   LOWER   LIMBS    OF    THE   VARIOUS 

TYPES    OF    CANCER. 

Prickle     Malignant  Cuboidal  Basal  Malignant 
wart                                                   mole 

Upper  limb    19               5                    0  4                 1 

Lower  limb    18               0                   4  6                 1 

Total   37  5  ~4  10  ~2 

There  was  a  total  of  fifty-eight  cases.  It  will  be  readily  seen  that 
the  commonest  tumor  is  the  spino-celled  one,  and  that  the  basal- 
celled  one  ranks  next.  Malignant  warts  are  much  commoner  on  the 
upper  than  on  the  lower  extremity,  while  the  reverse  is  true  of  the 
cuboidal-celled  carcinomas.  Cancer  of  the  upper  limb  is  just  about 
as  common  as  is  cancer  of  the  lower  limb. 

Prickle-celled  growths  originated  in  precancerous  dermatoses,  and 
metastasized  as  shown  in  table  2. 

TABLE    2. — METASTASES    OCCURRING     IN     PRICKLE-CELLED     GROWTHS. 

Total     Cases  followed     ^Metastatic 
Origin  cases         three  years  cases 

Eontgen  ray  dermatitis   2  2  2 

Scar  of  burn   S  5  3 

Scar   of  trauma    6  4  1 

Ulcer   2  0  f 

Wart    7  2  2 

Senile  keratosis    2  1  0 

' '  Pimple "    4  3  1 

Arsenic  keratosis   1  1  1 

Blastomycosis    1  1  0 

Bone    sinus    1  0  f 

Undetermined    3  1  1 

Total    37  20  "il 


24lJ  SKIN    CANCER. 

The  observation  that  eaiiecr  oi'i<rinatinj^  from  "Rontfjen  ray  der- 
matitis and  from  arsenic  keratosis  usually  motastasi/cs  is  borne  out 
here.  Cancer  springing  from  the  sears  of  bui-ns  lias  driven  a  rather 
hif^h  ]iercentaj;e  of  metastatic  <rro\vtlis. 

With  respect  to  the  inlliience  that  location  of  the  i)rimary  jj:ri)\\th 
has  on  the  liability  to  metastatic  formation,  table  3  is  presented. 

TABLE    3. METASTASE.S    Wmi    REFERENCE   TO   LOCATION    OF   l'KLAL\RY 

GROWTH. 

Total    Cases  followed     Metastatic 
cases        three  years  cases 

Finger 4  2  2 

Back  of  haiul   S  3  1 

Wrist 1  0  ? 

Forearm    1  0  ? 

Elbow    2  1  1 

Upper  arm  3  2  1 

Foot     2  2  1 

Ankle    n  1  0 

Lower  leg    7  4  2 

Knee    2  2  1 

Thigh    4  3  2 


In  such  a  small  scries  of  cases  it  is  impossible  to  determine  just 
what  influence  position  has  on  the  lia])ility  toward  metastasis,  but 
it  would  appear  to  have  very  little.  The  high  percentage  of  me- 
tastases in  the  followed  eases  is  notable.  It  will  probably  be  objected 
that  most  of  these  eases  were  surgical  ones,  and  that  they  were  se- 
vere cases  and  of  long  duration.  Now,  as  a  matter  of  fact,  in  six 
of  the  metastatic  cases  the  primary  cancerous  changes  had  been 
present  for  three  months  or  less.  In  one  notable  ease  there  was  a 
cancer  of  the  lower  leg  that  had  existed  for  two  months.  Under 
divided  doses  of  the  Rontgen  rays  the  primary  growth  healed  and 
stayed  healed,  but  five  years  later  metastases  developed  in  the  in- 
guinal glands  and  the  patient  succumbed.  In  the  other  ten  instances 
recurrence  in  the  glands  followed  amputation  in  five  cases  and  local 
surgical  removal  in  five.  The  nine  patients  Avho  stayed  cured  for 
more  than  three  years  were  all  subjected  to  local  operation  alone. 

A  study  of  these  few  figures  should  clearly  show  that  prickle- 
celled  cancer  of  the  skin  is  comparable  to  cancer  of  the  breast,  tongue 
or  lips,  and,  just  as  no  good  surgeon  would  think  of  treating  a  true 
cancer  of  these  organs  by  local  removal  alone,  so  should  he  shrink 
from  the  mere  local  removal  of  an  analogous  condition  of  the  cutis. 
In  many  instances  it  is  im])f)Ssiblo  to  determine  the  exact  nature  of 


TUMORS  A(;(;()Ri)(N<i  'lo  r.ofjA'i'ioN.  243 

;i  (MlljiMCOilK  (';i)i('ci'.  Here  t  lie  c(irfcc\  proccrl  ii  re  is  iiinlouhtcflly  tO 
excise  the  entire!  .^rowtli  jiihI  then  nnike  ;i,  study  of  it.  'J'o  attempt 
to  eure  a  malif^inmt  neoplnsin  of  the  limits  without  first  aseertain- 
inf?  its  nature  is  holli  foolhjiDly  ;iii<l  dnnj^MTous,  to  s;iy  tlie  least,  and 
will  nndonhtedly  I'csult  in  the  s;icrificc  of  many  lives. 

There  were  four  eases  of  cuhoidid-ccncd  fjiiifer,  one  of  whieh  orif^i- 
nated  from  a  varicose  uleer  of  the  h<f  ;ind  was  eured  by  the  cautery. 
One  developed  on  the  sear  of  ;i  bed  sor(!  on  the  thi^'h  ;ind  was  cured 
by  local  excision.  Another  o]-if»inated  in  a  senile  keratosis  on  the 
thigh  and  recurred  in  the  inguinal  glands  seventeen  months  after 
local  excision.  The  last  occui'i'cd  in  the  scar  of  a  trauma  on  the 
thigh,  and  promj^tly  recurred  in  tlie  inguinal  glands  after  local  ex- 
cision. All  growths  were  of  less  than  one  year's  duration.  All  were 
in  women.  It  is  plainly  evident  that  cuboidal-celled  cancer  is  anal- 
ogous to  spino-celled  cancer  in  the  way  that  it  metastasizes,  and  that 
it  should  be  treated  accordingly. 

There  were  five  cases  of  malignant  warts — three  on  the  back  of 
the  hand,  one  on  the  wrist,  and  one  on  the  forearm.  All  originated 
in  warty  growths.  Bloodgood  (see  page  212),  in  a  careful  study  of 
malignant  warts,  comes  to  tho  conclusion  that  they  never  metastasize 
and  that  complete  local  removal  is  sufficient  to  effect  a  cure.  Yet  in 
one  case  in  this  series  metastasis  and  death  did  follow  a  local  opera- 
tion, probably  not  a  complete  one.  Inasmuch  as  these  growths  are 
more  common  on  the  back  of  the  hand  than  elsewhere,  inasmuch  as 
they  show  a  spino-celled  structure,  and  inasmuch  as  they  very  rarely 
metastasize,  it  is  probable  that  those  who  have  stated  that  cancer  of 
the  hand  is  a  benign  affection  have  had  most  of  their  experience  with 
this  variety  of  tumor. 

There  w^ere  ten  basal-celled  cancers,  w^hich  arose  from  the  follow- 
ing dermatoses: 

Ulcer   6 

Scar  or  burn   1 

Pigmented  mole   1 

' '  Pimple  "    1 

Nodule    1 

They  arose  in  the  following  areas : 

Finger   1 

Hand  1 

Upper  arm   2 

Ankle    1 

Lower   leg    4 

Thigh     1 


244  SKIN    CANCLK. 

In  OIK'  ri'iuarUalik'  case  the  y:laiuls  lalur  Ucvelopcd  metastatic 
growths  that  showed  all  of  tiic  peculiarities  of  a  spino-celled  car- 
cinoma. So  far  as  known,  thei'e  were  no  other  metastases  in  this 
group. 

In  two  instanees  there  were  multii)le  melanotic  growths,  secondary 
to  pigmented  moles.  One  occurred  on  the  arm  of  a  woman  who  had 
suft'ered  but  a  single  trauma  to  a  ])igmented  mole.  This  immediately 
ulcerated  and  was  excised,  but  i>iniiipily  recui-i-ed.  Dui'ing  the  next 
five  years  there  were  a  number  of  local  operations.  She  then  entered 
the  hospital  with  a  mass  of  inoj^erable  glands  in  the  axilla,  l)ut  with 
no  signs  of  metastatic  growl  lis  in  the  body.  It  is  moi-e  than  ])rob- 
able  that  a  complete  early  operation,  including  the  axillai-y  glands, 
would  have  resulted  in  permanent  cure.  The  other  in.stance  oc- 
curred in  a  negro  man,  this  being  probably  the  only  case  on  record 
of  a  malignant  mole  in  one  of  his  race.  The  jirimary  growth  was  in 
the  sole  of  the  foot.  There  were  metastases  both  to  the  glands  and 
to  the  lungs,  and  death  speedily  ensued. 

Penis.'" — Cancer  of  the  jienis  is  not  especially  common,  although 
certain  authors  state  that  it  constitutes  nearly  1  percent  of  all  can- 
cers, undoubtedly  entirely  too  high  an  estimate. 

None  of  the  text-books  or  articles  that  the  author  has  read  has 
given  a  correct  account  of  the  pathology  of  these  cancers,  which  are 
analogous  to  those  occurring  upon  the  lip.  In  other  words,  there 
are  three  varieties — first,  the  common  prickle-celled  variety;  second, 
the  prickle-celled  malignant  warts;  and  third,  the  basal-celled  growths. 
Cuboidal-celled  tumors  also  occur  veiy  exceptionally,  thus  really 
making  four  varieties. 

The  common  malignant  tumors  are  the  squamous-celled  ones,  that 
usually  originate  on  the  glans  penis  or  mucous  mem])rane  of  the 
foreskin,  and  that  speedily  ulcerate  and  fungate.  ]\Ietastases  to  the 
inguinal  glands  are  nearly  always  present  after  a  short  time,  and 
hence  in  dealing  with  these  growths  it  is  necessary  not  only  to  re- 
move the  local  growth,  but  also  to  do  a  complete  dissection  of  the 
glands  on  both  sides.  This  should  be  done  as  upon  the  lip,  making 
a  block  dissection,  first  removing  the  glands  and  then  ami)utating 
the  penis.  Where  this  is  not  done,  there  are  ]»i;ic1ical]y  no  recov- 
eries, l)ut,  where  this  opei-ation  is  performed  in  early  cases,  the  per- 
centage of  cure  is  above  3G  pei'cent. 

The  i)rickle-celled  malignant  warls  may  lie  mistaken  for  venereal 
warts,  l)ut  speedily  ulcerate.  There  is,  however,  no  induration  about 
the  base,  and  an  extensive  local  removal  will  result  in  a  permanent 

»» Barney:  Annal.s  of  Surg.,   in07,   xlvi,   890.   244. 


TiiMoiJS  A(;(;()Hi)iN(;  to  i>o(;a'1'ion'.  245 

cure.  In  iiijui.v  of  llicsc  f;isc.s  it  is  iicc<'ss;i  ry  1o  ;i  in  put  ale  ifu!  (•t\(\  of 
the  j)cnis,  but  this  is  not  alvvayH  ncccissary. 

The  basal-('('ll(;<l  tumofs  fcK(!iiil)l(;  ollicf  incmljcrH  of  tlii.s  j^foup, 
sometimes  acting'  as  do  llic,  slowly  t^rowinj^  rodent  uW-ers,  and  some- 
times foriujii^  i'uu^Mtinfjj  masses,  which  hav(;  a  much  smoother  sur- 
face than  the  s(|uaiiious-cellc<l  neoplasms.  Jjocal  removal  will  suf- 
fice to  effect  a  cure. 

The  cuboidal-cellcd  j^rowths,  as  already  stated,  are  formed  from 
the  transitional  epithelium  normally  lyinj^  between  the  basal  and 
prickle  layers.  They  form  either  fungous  tumors  or  ulcers.  Treat- 
ment is  the  same  as  for  the  sciuamous-cclled  grow^ths. 

It  is  generally  conceded  that  many  cancers  of  the  penis  arise  from 
phimosis  and  retained  secretions,  and  that  perfect  cleanliness  would 
markedly  limit  their  number. 

Vulva. — Tumors  of  the  vulva  are  practically  identical  with  those 
upon  the  penis,  the  largest  number  being  of  the  very  malignant 
type.  Treatment  requires  not  only  local  excision,  but  removal  of  the 
inguinal  glands  as  well. 

Anus. — Considering  the  trauma  (due  to  the  passage  of  feces)  to 
which  the  anus  is  continually  subjected,  it  is  surprising  how-  rare 
tumors  of  this  region  are.  The  majority  of  the  malignant  tumors 
arise  from  the  squamous  epithelium  of  the  rectum  near  the  anal 
margin,  and  run  a  course  typical  of  the  prickle-celled  tumors  in  gen- 
eral. Metastasis  may  take  place  to  the  inguinal  glands  or  to  the 
lymphatic  glands  in  the  pelvis. 


INDEX 


Acaiit-lioma,  5.'5 

Acanthonui  julcnoidcs  cysticum,  103 
Acanthosis  nigricans,  55 
Adenocarcinoma     of     the     sebaceous 

glands,  96 
Adenocarcinoma  of  the  sweat  glands, 

98 
Adenoma  of  the  sebaceous  glands,  9G 
Adenoma  sebaceum,  107 
Adenoma  of  the  sweat  ducts,  99 
Adenoma  of  the  sweat  glands,  97 
Angiokeratoma,  53 


Benign  connective  tissue  tumors,  132 
Blastomycosis,  49,  165 


Callosity,  53 
Carcinoma : 

classification,  17 

according  to  origin,  18 

author's,  23 

Bloodgood's,  21,  22 

Hannover's,  17 

Krompecher's,    21 

Eibbert's,  20 

Thiersch's,  18 

Uuna's,  IS 
definition,  17 
degeneration,  25 

calcification,  26 

hyaline,  25 

keratoid,  26 

liquefaction,   26 

simple  softening,  26 
diagnosis,  15-i 

antecedent  dermatoses,  154 

age,    154 

duration,  155 

examination,  155 

gross  pathology,  156 


Carciiioiiia : 

diagno.sis — Coiif  '<]. 

history,  154 

microscopic   pathology,   156 

occupation,  154 

onset,   154 

palpation,  155 

sorodiagnostic   methods,    167 

symptoms,    154 
diagnosis   of: 

nodules,   158 

papillary  growths,  162 

scar-like  conditions,  165 

ulcers,    160 
diagnosis  between   cancer  and: 

benign  tumors,  158 

blastomycosis,   165 

chancre,   159,   161 

granulation  tissue,  163 

granuloma  pyogenicum,  163 

gumma,  100,  161 

lupus  erythematosus,  166 

lupus  vulgaris,  160,  166 

morphea,  166 

papillomatosis,   163 

serpiginous    syphilis,    161,    166 

sporotrichosis,    162 

traumatic  ulcers,  161 

tuberculosis   verrucosa   cutis,   164 

yaws,  165 
etiology : 

age,  32 

atypical  mitoses,  23,  30 

changes  in  tissue  balance,  30 

Cohnheim's    theory,    29 

congenitally      displaced      epithe- 
lium, 29 

contagion,   31 

filterable  virus,  32 

heredity,   32 

iuoculability,   31 

light.  33 

metaplasia,  29 
microorganisms,   30 


247 


248 


INDEX. 


Carcinoma : 

etiology — Cont  M. 
occupation,  33 
precancerous  domiatoscs,  35 
race,   32 
regression,   29 
sex,   32 
trauma,  33 
x-rays,    33 
frequency : 

in  American  Indians,  32 
in   American  negroes,   .".2 
in  the  two  sexes,  32 
histogenesis,  27 
histopathology,  24 
immunity,  29 
location: 
anus,  245 
arms,   240 
cheeks.  212 
chin,  213 
ears,  212 
eyelids,   210 
face,   212 
forehead,  209 
legs,  240 
lips,  213 
neck,  213 
nose,   212 
penis,    244 
scalp,  207 
temples,  209 
tongue,  223 
trunk,  239 
vulva,  245 
prognosis,    169 
prophylaxis,  173 
structure,  24 
toxins,  29 
treatment : 

acid  nitrate  of  mercury,  1S3,  198 
active  immunization,  202 
altofrequent  cytolosis,  185 
arsenic,  internally,  201 
arsenic  paste,  199 
autolysis,  202 
Bougard's  paste,  199 
cancer  vaccine,  202 
carbon  dioxide  snow,  201 
caustic  pastes,  199 


Carcinonui : 

treatment — Cont  M. 
caustic  potash,  199 
cautery,  actual,  182 
chromic  acid,  198 
colloidal  copper  salts.  202 
Coley's  serum,  141 
congelation,  201 
curettage,  182 
dessication,  150 
diathermy,    185 
electrolysis,  185 
excision,  179 
formalin,  200 
fulguration,   185 
liquid  air,  201 
mesothorium,  197 
methylene  blue,  201 
nitric  acid,  198 
passive  immunization,  202 
pyrogallol,  198 
radium,  195 
Rontgen  rays,  187 
Sherwell's  method,  182 
silver  nitrate,  199 
sulphuric  acid,  198 
supportative,  203 
thermopenetration,  185 

thoremedin,   197 
x-ray,  187 

zinc  chloride,  199 
varieties: 

arsenical,  40 

basal-celled,  59 
deep  ulcers,  78 
depressed  scar-like,   75 
flat  rodent  ulcers,  68 
fungous  tumors,  77 
niorphoa-like,   70 
nodular,  72 
rolled-edge,  73 

chimney  sweeps,  33,  41 

cuboidal-celled,  81 

en  cuirasse,  119 

extension,  121 

farmers,  33,  45 

hair  follicles,  92 

Jacob's  ulcer,  50 

melanotic  carcinoma,   111 

metastatic,  122 


INDF^X. 


249 


Carciiioniii: 

varieties — (''(nilM. 

ncvocarcinoiiKi,    1  1  1 

Paget 's    diH<;:i.se    oL'    tlie     nipplo, 
123 

])!iiiirfin  vvorkei-s,  .33,  41 

pricklc-cellcd,   84 

rodent  ulcer,  59 

sailors,    33 

sebaceous  glands,  95 

spino-cellcd,  84 

squamous-celled,  84 

sweat  ducts,  99 

sweat  glands,  96 

tar  workers,  33 

x-ray,    33 
Cellulomc  epitheliale  eruptif,  104 
Chicken  sarcoma,  34 
Chloroma,  149 
Cicatrix,  132 
Clavus,  53 
Corn,  53 

Criteria  of  malignancy,  24 
Cutaneous   horn,   53 

D 

Definition  of  cancer,  17 
Degenerations  of  cancer,  25 

E 

Endothelioma,  127 
Endothelioma  capitis,  207 
Epithelial  warts: 

acanthosis  nigricans,  55 

angiokeratoma,  53 

basal-celled,  benign,  5(j 

basal-celled,  malignant,  57 

callosity,  53 

common  wart,  54 

condyloma  acuminata,  55 

corn,  53 

cutaireous  horn,  53 

digitate  wart,  54 

filiform  wart,  54 

flat  wart,  54 

inflammatory  warty  growths,  52 

malignant  wart,  5(3 

pedunculated  wart,  55 

prickle-celled  malignant  wart,  57 


Kpitliclin)  wart8 — Cont 'rl. 
Hcbr)rrlir;ic  wart,  37 
semiglobular  wart,  55 
senile  wart,  37 
venereal  wart,  55 


Fibroma,   133 

Fibroma  molluscum,  133 


H 


Hemangioendothelioma    cutis    papulo- 

sum,  104 
Hemangioendothelioma,  127 
Hemangioma,  135 
Hodgkin's  disease,  149 


Jacob's  ulcer,  59 


K 

Keloid,  132 

Keratosis  follicularis,  41 

Keratosis: 

arsenical,  40 

follicularis,  41 

seborrheic,  37 

senile,  37 

x-rav,  46 


Leukemia  cutis,  149 
Lipoma,  134 
Lupus  erythematosus,  49 
Lupus  vulgaris,  47 
LjTnphangioendothelioma,  127 
L\Tnphangioma,  135 
Lymphangioma  circumscriptum,  136 
LATiiphangioma   tuberosum   multiplex, 

104 
Lymphodermia  xDerniciosa,  150 
Lpnphoma,  14S 


250 


INDEX. 


M 

Muliynant  wart,  56 

Marjulin's  ulcer,  47 

Melanoma,  111 

Mc'laiiotif  oaroiiioma,  111 

Melaiiutic  sarcoma,  111 

Metastases,  2S 

Mole-ingmentcd,  35 

Molliiscum  conta}j;iosum,  53 

Multiple    benign    cystic    epitheliuma, 

102 
Multiple  myeloma,  148 
Myoma,   l.'l-i 
Mycosis  fuugoides,  150 

N 

Nevi   cyst-epitheliomatosi   papulosum, 

104 
Nevi  epitheleaux  cystiques,  104 
Nevo-carcinoma,  111 
Nevo-xantlio-endothelioma,  131 
Neuroma,  134 


Osteoma,   134 


Paget 's  disease  of  the  nipple,  123 
Papilloma,  21,   50 
Papillomatosis,  lO.'J 
Perithelioma,  127 
Pigmented  mole,  35 
Precancerous  dermatoses,  35 

arsenical  keratoses,  40 

blastomycosis,  49 

cutaneous  horn,  41 

eczema,  50 

farmer's  skin,  45 

fibroepithelioma,  50 

inflammatory  dermatoses,  50 

keratosis  follicularis,  41 

leg  ulcer,  49 

lichen  planus,  50 

lupus  erythematosus,  49 

lupus  vulgaris,  47 

nevi,  50 

Paget 's  disease  of  the  nipple,  47 

papilloma,  50 


Precancerous  dermatoses — Cont  'd. 
paraflin  worker's  dermatitis,  41 
pigmented  mole,  35 
psoriasis,  50 
sailor's  skin,   45 
seborrheic  wart,  37 
senile  wart,  37 
sinii)le  keratosis,  39 
sinus,  50 
syphilis,  49 
ulcer,  47,  49 
wen,  50 

x-ray  dermatitis,  46 
xeroderma  pigmentosum,  42 


B 


Recurrence,  28 
Rodent  ulcer,  59 


Sailor's  skin,  45 
Sarcoid,  146 

Boeck  type,  146 

Darier  type,  146 

nodular  type  of  extremities,  147 

Spiegler-Feudt  type,  144 
Sarcoma : 

angiosarcoma,  138 

classification,  137 

giant-celled,  141 

kaposi  multiple  hemorrhagic,  143 

sarcomatosis,  142 

small  round-celled,  138 

spindle-celled,  139 
Sebaceous  glands: 

adenoma  of,  95 

carcinoma  of,  95 

hypertrophy  of,  95 
Seljorrheic  wart,  37 
Senile  wart,  37 
Spiradenoma,  98 
Steatadenoma,  109 
Sweat  ducts: 

carcinoma  of,  100 

syringoadenoma,  99 
Sweat  glands: 

adenoma  of,  97 

carcinoma  of,  98 

hypertrophy  of,  96 


INDEX. 


251 


Syringoadcnoma,  99 
Syi'ingocystadoiioma,  104 

T 

Toxins,  29 
Tiichoopithclioma,  93 


Verruca,  see  wart 


W 


Wart: 

basal-celled,  56 
benign,  52 
common,  54 


Wart— Cont'd. 

di Imitate,  54 

filifiinii,   51 

malignant: 
basal-col  I'd,  57 
pricklc-f;':li(;d,  57 

pedunculated,  55 

Hobonheic,  o7 

semiglobular,  55 

senile,  37 

venereal,  55 
Wen,  50 


X-ray  dermatitis,  46 
Xeroderma  pigmentosum,  42 


V-''     '^   ■' 


Date  Due 


OCT  ^ 


9  ms 


